Digital Ulcers (finger and toe sores)

Link between Raynaud's and Scleroderma

Digital ulcers (or sores on the fingers or toes) can be a classic outward sign of scleroderma. The combination of Raynaud's and skin changes in scleroderma can lead to tissue breakdown resulting in a digital ulcer.

Around 40% of people with scleroderma will develop digital ulcerations.

Digital ulcers are often slow to heal because of poor circulation and tight skin; this does mean that infection is common as the healing time is prolonged. Digital ulcers can have a huge impact on quality of life by making daily living difficult from washing to preparing food.

It is important to closely manage ulcers and seek medical advice if you notice any sign of infection. Some people with persistent ulcers can develop gangrene and scleroderma specialist nurses must manage this. How quickly digital ulcers heal varies hugely from one person to another and what works for you may not for someone else. A tailored approach is required for each person.

There are now much better treatment options for digital ulcers than ever before, from natural therapies to high cost drugs. These are explained below.

Treatments

Antioxidant treatments

Vitamin C helps your body repair blood vessels, which are important to help healing tissue. Vitamin E helps nourish and support your skin. Natural plant oils such as Evening Primrose Oil, starflower oil Linseed and Flaxseed oils support healthy circulation also important for tissue repair. More details on the above treatments are outlined in our nutrition section.

Oral Vasodilators for Raynaud's control

You may already be on a tablet for your Raynaud's. E.g, Losartan, Diltiazem, Nifedipine etc. These may need to be increased or you may need to be prescribed more than one of these types of tablets to help an ulcer heal. Stronger vasodilators such as Sildenafil are now being used more commonly and can be prescribed by your GP. Your GP, local Consultant or Specialist Nurse should carry out medication optimisation.

Intravenous vasodilators

Such as Iloprost are used in more severe cases where the tissue is threatened or if digital ulcers are not healing with the standard treatments. Iloprost causes vasodilation to help get the blood flowing to the extremities to help heal ulceration. It is more potent, as it is given via a drip so goes directly into the blood stream.

Antibiotics

If an ulcer is infected you will require antibiotics as soon as possible. Your GP or local hospital can facilitate this for you. If the infection doesn't heal your Practice Nurse can swab the wound to see what type of infection it is and then change the antibiotics accordingly. In severe cases intravenous antibiotics may have to be given, which would be administered at your local hospital or specialist unit.

Bosentan

This is a high cost drug that is approved via the NHS England specialised commissioning policy for digital ulceration. There are strict criteria each patient needs to fulfil to qualify for treatment and is only approved in the most severe cases. However, it is the only licensed therapy available specifically to target digital ulceration.

Dressings

Specialist wound management is also helpful to ensure appropriate wound cleansing and effective, targeted dressings to help the wound heal, help fight infection and offer protection of the digital ulcer. Your Specialist Nurse or your Practice Nurse can help with this. There are numerous dressings and topical treatments now available.

Pain control

Pain management is also essential as digital ulcers can cause debilitating pain as well as affecting hand function. You may need additional medication to help with digital ulcer pain. This can also be facilitated by your GP or local hospital team; do not be afraid to ask!

Smoking

This is the worst thing you can do if you are prone to digital ulceration. Smoking will hinder tissue repair and constrict your blood vessels. It is essential to stop to optimise blood flow. You can get help to stop by accessing your local smoking cessation service via your GP or local hospital.

As with all aspects of your condition, managing digital ulceration requires early, proactive intervention. Compliance with all medication, treatments and dressings is essential to get the best outcome.

Supported by the Royal Free Hospital, London.

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