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. 2025 Apr 30:23971983251336616.
doi: 10.1177/23971983251336616. Online ahead of print.

Clinicians' perspectives concerning treatment initiation and escalation strategies for digital ulcers in patients with systemic sclerosis

Giulia Campanaro  1 , Giulia Bandini  1 , Alessia Alunno  2 , Stefano Di Donato  3 , Begonya Alcacer-Pitarch  3 , Ilaria Galetti  4   5 , Barbara Ruaro  6 , Silvia Bellando Randone  7 , Alberto Moggi Pignone  1 , Marco Matucci-Cerinic  8   9 , Zsuzsanna H McMahan  10 , Michael Hughes  11   12
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Clinicians' perspectives concerning treatment initiation and escalation strategies for digital ulcers in patients with systemic sclerosis

Giulia Campanaro et al. J Scleroderma Relat Disord. .

Abstract

Objectives: Digital ulcers (DUs) are a major cause of pain and disability in systemic sclerosis (SSc) patients and remain a major treatment challenge. Our aim was to explore clinicians' perspectives towards treatment initiation and escalation, akin to a 'Treat to Target' (T2T) strategy.

Methods: SSc clinicians were invited to participate in an online survey.

Results: A total of 173 responses (75% rheumatologists) were obtained from 33 countries. When initiating a change in oral drug therapy for SSc-DUs, most (80%) respondents would consider adding new medication to existing treatment, and 50% would increase existing treatment dose. Time to assess the impact of treatment change varied considerably, with around half (43.6%) waiting 1 month. Endothelin receptor antagonists, phosphodiesterase type-5 inhibitors and prostanoids were considered most efficacious for DU prevention, with good perceived efficacy from calcium channel blockers and moderate benefit from anti-platelet agents and immunosuppression. Side effects (e.g. headache and peripheral oedema) are perceived to be a significant issue with oral vasodilatory/vasoactive therapies in many patients. The highest rated T2T targets were (1) complete absence of new/recurrent DUs (63%), (2) reduction >50% in the number of DU recurrence (52%) and (3) reduction in DU healing time (37%) and reduction in DU pain >50% (37%). The most frequent reasons for hospitalisation were to administer intravenous treatment (91%) and DU complications (87%). Surgery is reserved for the threatened digit (e.g. gangrene), underlying calcinosis and failure of medical therapy.

Conclusion: Significant heterogeneity currently exists concerning treatment initiation and escalation for SSc-DUs, potentially amenable to a T2T strategy.

Keywords: Digital ulcers; Raynaud’s; T2T; management; pharmacological; scleroderma; systemic sclerosis; vascular.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MH is Chair of a Data Safety Monitoring Board: SHED SSc–SHarp dEbridement of Digital ulcers in Systemic Sclerosis: a multi-centre Randomised Controlled Trial feasibility study (REC reference: 21/YH/0278) and receives research funding and speaker fees from Janssen, outside of the submitted work. None of the other authors report any relevant conflicts of interest.

Figures

Figure 1.
Figure 1.
Targets for a future DU T2T strategy. Respondents indicated on a binary scale their preference (i.e. whether to include or exclude) potential target/s for a hypothetical future T2T strategy for SSc-DUs. Data are presented as the percentage of respondents who considered whether an item could be a potential treatment target.
Figure 2.
Figure 2.
Factors influencing clinicians decision-making concerning proposal for admission to hospital (a) and surgery (b) to treat SSc-DUs.
See this image and copyright information in PMC

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