. 2025 May 15:23971983251339821.

doi: 10.1177/23971983251339821. Online ahead of print.

Recommendations for the local management of digital ulcers in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) 'Ad hoc committee'

Corrado Campochiaro¹, Yossra A Suliman², Dilia Giuggioli³, Pia Moinzadeh⁴, Alessia Alunno^{5

6}, Jan W Schoones⁷, Murray Baron⁸, Lorinda Chung⁹, Laura Ross^{10

11}, Nancy Maltez¹², Begonya Alcacer-Pitarch¹³, Khadija El-Aoufy¹⁴, Yannick Allanore¹⁵, Francesco Del Galdo¹³, Christopher P Denton¹⁶, Oliver Distler¹⁷, Tracy Frech¹⁸, Daniel E Furst¹⁹, Dinesh Khanna²⁰, Thomas Krieg²¹, Masataka Kuwana²², Marco Matucci-Cerinic^{1

23}, Janet Pope²⁴, Michael Hughes^{25

26}

Affiliations

¹ Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milano, Italy.
² Assiut University Hospital, Assiut, Egypt.
³ Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy.
⁴ University Hospital of Cologne, Cologne, Germany.
⁵ Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
⁶ Internal Medicine and Nephrology Unit, Department of Medicine, ASL Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy.
⁷ Directorate of Research Policy (formerly Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands.
⁸ Jewish General Hospital, McGill University, Montreal, QC, Canada.
⁹ School of Medicine, Stanford University, Palo Alto VA Health Care System, Palo Alto, CA, USA.
¹⁰ The University of Melbourne, Melbourne, VIC, Australia.
¹¹ St Vincent's Hospital, Melbourne, VIC, Australia.
¹² The University of Ottawa, Ottawa, ON, Canada.
¹³ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹⁴ Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
¹⁵ Paris Descartes University, Paris, France.
¹⁶ University College London, London, UK.
¹⁷ Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
¹⁸ Veterans Affairs Medical Center, University of Utah, Salt Lake City, UT, USA.
¹⁹ University of California, Los Angeles, Los Angeles, CA, USA.
²⁰ University of Michigan, Ann Arbor, MI, USA.
²¹ Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany.
²² Nippon Medical School, Tokyo, Japan.
²³ Vita Salute San Raffaele University, Milano, Italy.
²⁴ Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
²⁵ Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK.
²⁶ Division of Musculoskeletal and Dermatological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.

PMID: 40385097
PMCID: PMC12084219
DOI: 10.1177/23971983251339821

Recommendations for the local management of digital ulcers in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) 'Ad hoc committee'

Corrado Campochiaro et al. J Scleroderma Relat Disord. 2025.

. 2025 May 15:23971983251339821.

doi: 10.1177/23971983251339821. Online ahead of print.

Authors

Affiliations

¹ Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milano, Italy.
² Assiut University Hospital, Assiut, Egypt.
³ Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy.
⁴ University Hospital of Cologne, Cologne, Germany.
⁵ Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
⁶ Internal Medicine and Nephrology Unit, Department of Medicine, ASL Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy.
⁷ Directorate of Research Policy (formerly Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands.
⁸ Jewish General Hospital, McGill University, Montreal, QC, Canada.
⁹ School of Medicine, Stanford University, Palo Alto VA Health Care System, Palo Alto, CA, USA.
¹⁰ The University of Melbourne, Melbourne, VIC, Australia.
¹¹ St Vincent's Hospital, Melbourne, VIC, Australia.
¹² The University of Ottawa, Ottawa, ON, Canada.
¹³ Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹⁴ Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
¹⁵ Paris Descartes University, Paris, France.
¹⁶ University College London, London, UK.
¹⁷ Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
¹⁸ Veterans Affairs Medical Center, University of Utah, Salt Lake City, UT, USA.
¹⁹ University of California, Los Angeles, Los Angeles, CA, USA.
²⁰ University of Michigan, Ann Arbor, MI, USA.
²¹ Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany.
²² Nippon Medical School, Tokyo, Japan.
²³ Vita Salute San Raffaele University, Milano, Italy.
²⁴ Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
²⁵ Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK.
²⁶ Division of Musculoskeletal and Dermatological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.

PMID: 40385097
PMCID: PMC12084219
DOI: 10.1177/23971983251339821

Abstract

Introduction: Digital ulcers (DUs) stand out as one of the most prevalent and clinically meaningful manifestations of systemic sclerosis (SSc) and are associated with significant morbidity. While systemic (pharmacological) therapy is currently established as the 'standard of care', effective local ulcer management remains crucial for all cases of DUs. This is particularly true for patients who cannot tolerate systemic treatments or in the case of refractory SSc-DUs. On this background, there is a pressing demand for the formulation of evidence-based guidelines to assist clinicians and patients in navigating the local treatment options for DUs.

Methods: A steering committee of international experts was established by the World Scleorderma Foundation (WSF) Digital Ulcer (DU) ad hoc committee. Two systematic literature reviews on local non-surgical and surgical treatments for the management of SSc-DUs were performed to inform the development of local treatment recommendations for SSc-DUs. Consensus methodology was used to develop the final treatment recommendations.

Results: Six overarching treatment principles and eight local treatment recommendations (five non-surgical and three surgical) were agreed upon for the management of SSc-DU. Among topical non-surgical options, botulin toxin can be conditionally recommended for refractory and/or severe DUs. Among surgical treatments, autologous adipose tissue grafting might be recommended for DU healing when combined with background systemic treatments.

Conclusion: These recommendations are specifically tailored to guide treatment decisions concerning both local and non-pharmacological approaches to managing SSc-related DUs. Our work has highlighted a notable quality gap in comparison to systemic treatments, underscoring the scarcity of high-quality studies concerning this topic.

Keywords: Systemic sclerosis; TIME; adipose tissue; botulin; debridement; digital ulcers; local treatment; non-pharmacological; scleroderma; surgical.

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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 reports research funding and speaker fees from Janssen, outside of the submitted work. 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). MK has received consulting fees, speaking fees and/or research grants from Argenx, Asahi Kasei Parma, AstraZeneca, Boehringer Ingelheim, Chugai, GSK, Janssen, Kissei, MBL, Mochida, Ono Pharmaceuticals and Tanabe-Mitsubishi. LC has received consulting fees from Mitsubishi Tanabe, Genentech, Kyverna, IgM Biosciences, Lilly and Janssen. DG has received speaking fees from Boehringer Ingelheim and Janssen. OD has/had a consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: 4P-Pharma, AbbVie, Acceleron, Alcimed, Altavant, Amgen, AnaMar, Argenx, Arxx, AstraZeneca, Blade, Bayer, Boehringer Ingelheim, Cantargia AB, Catalyze Capital, Corbus, CSL Behring, Galderma, Galapagos, Glenmark, Gossamer, Horizon, Janssen, Kymera, Lupin, Medscape, Merck, Miltenyi Biotec, Mitsubishi Tanabe, Nkarta Inc, Novartis, Orion, Prometheus, Redxpharma, Roivant, EMD Serono, Topadur and UCB. Patent issued ‘mir-29 for the treatment of systemic sclerosis’ (US8247389, EP2331143). Co-founder of CITUS AG. None of the other authors report any relevant conflicts of interest.

Figures

**Figure 1.**
Network diagram recapitulating surgical and non-surgical treatment recommendations.

See this image and copyright information in PMC

References

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Recommendations for the local management of digital ulcers in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) 'Ad hoc committee'

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Recommendations for the local management of digital ulcers in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) 'Ad hoc committee'

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