Abstract
Background:Digital ulcers (DUs) are one of the main burdens in patients with systemic sclerosis (SSc) as they have a major impact on quality of life and prognosis. Some DUs are associated with the presence of subcutaneous calcinosis (SC) that may worsen their management, and the prognosis of these DUs is still not well defined.Objectives:To define the characteristics of SSc patients with DUs related to SC and analyze the impact on prognosis and on healing time.Methods:We prospectively collected data from DUs of the hands evaluated in our dedicated wound-care outpatient clinic from October 2018 to August 2019. Fifty-five patients were enrolled (50 females, 18 with limited-SSc and 37 with diffuse-SSc, mean age 62.3±17.2 years). For every DU we collected: presence/absence of calcinosis, pathogenesis (spontaneous, post-traumatic), area of DU, location (fingertip, periungual area, metacarpophalangeal, proximal/distal interphalangeal-PIP/DIP), VAS-pain at the baseline and after two weeks, local signs of infection (edema, redness), deep wound swab results and time to the healing. Additionally, we calculated the wound-bed score (WBS), at the baseline and we correlated the total score with the time of healing. All the ulcers were managed with weekly treatment following a definite protocol: wound cleansing, disinfection, mechanic debridement, application of antiseptic dressing.Results:Out of 98 DUs evaluated, 24 (24.5%) were associated with SC. Patients with SC were older than those without calcinosis (67.1+-16.9 vs 59.4+-16.9 p<0.05) and were more frequently affected by lc-SSc (18 – 75% vs 6 – 25% p<0.001). There were no significant differences between the mean areas of DUs (SC 22mm2vs non-calcinosis 30.8mm2) neither in the localization of the ulcers: fingertip (14-61% vs 34-49.3%), periungual area (4-17.4% vs 16-23.2%), PIP (2-9% vs 13-18.9%), DIP (2-9% vs 9-13%) and MCP (1-4% vs 4-5.8%). The VAS-pain was not statistically different at the baseline (6.0 for SC vs 5.4), neither after 2 weeks (3.8 vs 3.2). Although the presence of local signs of infection was similar (5-20.8% vs 14-18.9%), the positivity for the wound swab was higher in SC compared with those without calcinosis (6-26.1% vs 9-11.5%; p=0.05).All the DUs treated in our outpatient clinic healed but those with SC required more weeks (10.4±7.9 vs. 7.13±5.7; p=0.03). The WBS was similar in the two groups (8.96+-0.46 in SC vs 9.43+-0.33) and was negatively correlated with the time of healing (r=-0.24, p=0.02).Conclusion:Although DUs with calcinosis have a different pathogenesis compared to those without SC, the location, dimensions and DU-related pain are similar in both groups. Despite these aspects, DUs associated with calcinosis are more prone to be infected and require more time to heal; the WBS may represent a simple, easy-calculated score to predict the time for DUs healing. The presence of calcinosis may represent a negative prognostic factor in the management of SSc-DUs.
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