Pharmacological management of digital ulcers in systemic sclerosis - what is new?

[INTRODUCTION] Digital ulcers (DUs) develop in approximately 50% of patients with systemic sclerosis (SSc). DUs are painful and disfiguring, with a major impact on hand function and quality of life. Although some pharmacological treatments have been shown to confer benefit, new treatments are badly needed: SSc-related DUs are an area of major unmet clinical need. This review focuses on advances in pharmacological management.

[AREAS COVERED] DU definition, types of DU, and clinical burden are briefly described and the general approach to multidisciplinary management, followed by a more detailed description of pharmacological management, with particular reference to blocking the endothelin pathway, and supplementing the nitric oxide and prostacyclin pathways. Other aspects of pharmacological management, including analgesia and botulinum toxin injections are also discussed. To inform the review, the MEDLINE database was searched for English-language papers published between 1946 and December 2022 using search terms: 'systemic sclerosis (scleroderma)' and 'digital ulcer' or 'finger ulcer' or 'digital vasculopathy.'

[EXPERT OPINION] The key challenges to preventing and treating DUs are to develop and validate reliable, sensitive outcome measures to facilitate clinical trials, and then to undertake trials of emerging new approaches to treatment, including topical therapies and (in early disease) vascular remodeling therapies.