title: Systematic review of non-surgical treatments for early dupuytren's disease.
abstract: Dupuytren's disease is a common fibrotic disorder of the palm characterized by the development of progressive flexion deformities in the digits, leading to significant functional impairment. Surgical excision remains the most common treatment. However, this is only indicated in patients with established contractures rather than those with early disease. Early disease is generally characterized by the presence of palmar nodules with limited or no contracture of the fingers. The ideal treatment would be directed at patients with early progressive disease to prevent future deterioration. Various non-surgical treatment modalities have been described but there is currently no systematic assessment of the role and efficacy of these treatments in patients with early disease.
  
  
  
  Using a PICOS analysis we reviewed publications of studies of patients with early disease who had received physical therapies, pharmacological treatment, or radiotherapy. Following PRISMA guidelines titles and abstract were screened using predefined criteria to identify those reporting outcomes specifically relating to the treatment of early disease. In the absence of a definition of early disease studies were included if early DD was described clinically, with digital contractures not exceeding 30°, Tubiana grades N to 1, and which reported identifiable data. Studies were excluded if data for early DD patients could not be extracted for analysis.
  
  
  
  In this systematic review, 26 studies were identified and analyzed to evaluate the effect of pharmacological therapy (n = 11), physical therapy (n = 5) and radiotherapy (n = 10) on early Dupuytren's disease. The studies comprised 20 case series, 1 cohort study with the remainder reporting case studies. All publications were graded level of evidence 4 or 5 assessed using the Oxford Centre for Evidence Based Medicine grading. Narrative descriptions of the data are presented.
  
  
  
  Physical therapies were the most robustly assessed, using objective measures but the studies were under powered, providing insufficient evidence of efficacy. Intralesional steroid injection and radiotherapy appeared to lead to softening of nodules and to retard disease progression but lacked rigorous evaluation and studies were poorly designed. There is an urgent need for adequately powered double blinded randomized trials for this common disorder which affects 4 % of the population.
  
  
  
  The protocol was registered ( CRD42015008986 16 November 2015) with the PROSPERO international prospective register of systematic reviews.
authors.affiliation: Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, UK. cathy.ball@kennedy.ox.ac.uk.
authors.forename: Catherine
authors.identifier: 0000-0003-3505-5020
authors.initials: C
authors.lastname: Ball
authors.affiliation: Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, UK.
authors.forename: David
authors.initials: D
authors.lastname: Izadi
authors.affiliation: Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, UK.
authors.forename: Liaquat Suleman
authors.initials: LS
authors.lastname: Verjee
authors.affiliation: Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, UK.
authors.forename: James
authors.initials: J
authors.lastname: Chan
authors.affiliation: Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, UK.
authors.forename: Jagdeep
authors.initials: J
authors.lastname: Nanchahal
mesh_terms: D018450:Disease Progression; D004358:Drug Therapy; D004387:Dupuytren Contracture / Q000628:therapy*; D006225:Hand / Q000473:pathology*; D006801:Humans; D026741:Physical Therapy Modalities; D011878:Radiotherapy; D016896:Treatment Outcome
keywords: Dupuytren’s disease; Pharmacological therapy; Physical therapy; Radiotherapy; Systematic review