Page updated: 21 April 2021
News update - our latest webinar on digital ulcers
Please click here to watch our recent webinar on digital ulcers. Professor Ariane Herrick shares key information, including who is at risk, why ulcers develop and where, signs of infection, prevention and treatments, as well as some practical tips and advice. We hope you find this useful.
What are Digital Ulcers?
A digital ulcer is a break in the skin of a finger or (less commonly) a toe. Digital ulcers can be extremely painful and can become infected making daily activities very problematic
Who is at Risk of Developing a Digital Ulcer?
Those people with systemic sclerosis (scleroderma) are at risk. Digital ulcers occur approximately in half people with systemic sclerosis (scleroderma). Digital ulcers do not occur in people with primary Raynaud’s, where there is no underlying medical cause. In contrast approximately half of all people with scleroderma, who experience secondary Raynaud’s due to this medical condition, are likely to develop a digital ulcer at some point in their life. Scleroderma and secondary Raynaud’s can lead to the occurence of an ulcer. If you have poor blood supply to your fingers, you are at risk of a digital ulcer.
Why do Ulcers Develop?
Ulcers normally develop due to a combination of poor blood flow, as a result of blood vessel damage caused by scleroderma and the skin changes (being more tight) in scleroderma. They may also be triggered by trauma to the digit, particularly over the backs of the hands and joints where they are more exposed. They may also develop over areas of calcinosis (calcium deposits beneath the skin found in some people with scleroderma).
Link with Raynaud's and Scleroderma
Digital ulcers (or sores on the fingers or toes) can be a sign of scleroderma. They do not occur in people with ‘primary’ Raynaud’s phenomenon. The combination of Raynaud's (leading to poor blood supply) and skin changes in scleroderma can lead to tissue breakdown resulting in a digital ulcer.
Around 40% of people with scleroderma will develop digital ulcers.
Digital ulcers are often slow to heal because of poor circulation and tight skin; this also means that infection is common, and infection can prolong healing time. Digital ulcers can have a huge impact on quality of life by making daily living difficult from washing to preparing food. Digital ulcers can be very painful.
Signs of Infection
It is important to closely manage ulcers and seek medical advice if an ulcer develops and especially if you notice any of the typical signs of infection which might include:
- Increased pain
- Discharge of pus
- Swelling (e.g. of the fingertip).
This is a key point – early intervention reduces the chances of the ulcer becoming chronic. At this point it is important to see a doctor or specialist nurse and to be assessed, as you may need to start on antibiotics. If in doubt get it checked out early to avoid the infection getting worse. Occasionally gangrene can develop, but this is very rare. How quickly digital ulcers heal varies considerably from one person to another – some heal quickly but others can take several weeks or even longer.
Prevention of Digital Ulcers
Minimise your chance of developing digital ulcers by maintain good circulation by keeping your hands and feet warm. Skin protection is very important, try to reduce exposure to water (which can dry the skin out and lead to fissures or breaks in the skin), for example, by using a dishwasher if possible. Use soap substitutes such as aqueous cream and ensure that you moisturise your hands every time after you put them in water. If you manicure your cuticles then do be careful to do this gently, so as not to damage the skin.
Your doctor will probably recommend medication to improve blood flow, with the aim not only of helping the Raynaud’s but also of reducing the likelihood of ulcers.
Smoking is one of the worst things 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 the 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.
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.
Oral vasodilators for Raynaud's Control
You may already be on medication for your Raynaud's e.g. nifedipine, sildenafil, or losartan. This medication may need to be increased or you may need to be prescribed more than one of these medications in combination to help an ulcer heal. 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 widens blood vessels and therefore helps to get the blood flowing to the extremities to help heal ulceration. Iloprost is given via a drip and is delivered directly into the bloodstream.
If an ulcer is infected you will require antibiotics as soon as possible. Your GP or local hospital can facilitate this for you. Especially if the infection does not resolve, 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.
This is a drug that is approved for preventing recurrent digital ulcers in people with scleroderma. There are strict criteria that each patient needs to fulfil to qualify for treatment, which is only approved in the most severe cases.
Specialist wound management is also helpful to ensure appropriate wound cleansing. Effective, targeted dressings can help the wound to heal, fight infection and protect the affected area. Your Specialist Nurse or Practice Nurse can help with this. There are numerous dressings and topical treatments now available.
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!
If an ulcer is not healing then sometimes surgery is required. The commonest surgical procedure is debridement of the ulcer, which involves removing unhealthy tissue. Other surgical procedures may be required in a small minority of people with non-healing ulcers.
Other Treatments Which May be Helpful
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 and are also important for tissue repair. More details on the above treatments are outlined in our nutrition section.
Conclusions with Tips and Tricks
Digital ulcers are a major cause of pain and disability. Early diagnosis is one of the most important aspects of treatment, it is important you seek advice from your healthcare professional if you are unsure. Ulcers often become infected, requiring an antibiotic. There are many different aspects to treatment, including wound care, pain-killers, medications to improve blood flow, and (sometimes) surgery
Research is ongoing to develop new safe and effective treatments
With thanks to clinical reviewer:
Ariane Herrick is Professor of Rheumatology, University of Manchester and Honorary Consultant Rheumatologist, Salford Royal NHS Foundation Trust. Her main clinical and research interests are Raynaud's phenomenon and systemic sclerosis-spectrum disorders. She is past-president of the Scleroderma Clinical Trials Consortium (SCTC) and a vice-president of Scleroderma and Raynaud's UK (SRUK).