title: Non-healing ischaemic digital ulcer in a systemic sclerosis patient: a challenging clinical case.
abstract: Ischaemic digital ulcers (DUs) are an indicator of the severity of the microangiopathy in patients with systemic sclerosis (SSc). DUs are a frequent complication, affecting about 50% of patients with SSc, and are often recurrent. In cross-sectional studies involving patients with SSc, the frequency of ischaemic DUs was 12-16% with a major impact on hand function and quality of life. Effective therapy for DUs remains elusive. Intravenous iloprost has been demonstrated to have a positive effect on healing of active DUs. Bosentan, an oral endothelin receptor antagonist, only showed a benefit in preventing the occurrence of new DUs. Despite limited evidence, recent guidelines have recommended phosphodiesterase type 5 inhibitors as an option. Injection of botulinum toxin and digital sympathectomy have been increasingly used for ischaemic DUs. Here we present the complex case of a SSc patient already treated with sildenafil and bosentan in whom an active DU was successfully treated with botulinum toxin A. Despite the lack of a randomised controlled trial, results are encouraging for the use of botulinum toxin in the treatment of DUs and could perhaps help to avoid some amputations, as in the present case.
authors.affiliation: Vascular Medicine Department, Grenoble University Hospital, Grenoble, France.|UMR 1042-HP2, INSERM and University Grenoble-Alpes, Grenoble, France.
authors.forename: Sophie
authors.initials: S
authors.lastname: Blaise
authors.affiliation: UMR 1042-HP2, INSERM and University Grenoble-Alpes, Grenoble, France.|Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alps University Hospital, Grenoble, France.
authors.forename: Matthieu
authors.initials: M
authors.lastname: Roustit
authors.affiliation: Hand Surgery Department, Grenoble Alps University Hospital, Grenoble, France.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Forli
authors.affiliation: Vascular Medicine Department, Grenoble University Hospital, Grenoble, France.
authors.forename: Bernard
authors.initials: B
authors.lastname: Imbert
authors.affiliation: UMR 1042-HP2, INSERM and University Grenoble-Alpes, Grenoble, France.|Clinical Pharmacology Unit, INSERM CIC1406, Grenoble Alps University Hospital, Grenoble, France.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Cracowski
mesh_terms: D061605:Administration, Intravenous; D000284:Administration, Oral; D000077300:Bosentan; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D005385:Fingers / Q000503:physiopathology*; D006801:Humans; D016285:Iloprost / Q000009:adverse effects* / Q000627:therapeutic use*; D008875:Middle Aged; D058986:Phosphodiesterase 5 Inhibitors / Q000627:therapeutic use; D012595:Scleroderma, Systemic / Q000188:drug therapy*; D000068677:Sildenafil Citrate / Q000627:therapeutic use; D012883:Skin Ulcer / Q000188:drug therapy* / Q000209:etiology*; D013449:Sulfonamides / Q000627:therapeutic use; D016896:Treatment Outcome; D014945:Wound Healing / Q000187:drug effects
chemical_list: D058986:Phosphodiesterase 5 Inhibitors; D013449:Sulfonamides; D000068677:Sildenafil Citrate; D019274:Botulinum Toxins, Type A; D016285:Iloprost; D000077300:Bosentan
keywords: Botulinum toxin A; Digital ulcer; Raynaud phenomenon; Systemic sclerosis; Therapeutic