Answers to Some Frequently Asked
Questions
Originally published in Scleroderma Voice, 2004
#2)
Editor's note: You can skip
directly to the subheads that interest you, by clicking
on these links:
The Scleroderma
Foundation receives questions on a daily basis from
patients seeking answers to health issues.
Although scleroderma is a highly individualized disease,
we have found that some concerns are very common among
those affected. We thought this forum would be a perfect
opportunity to revisit some of these concerns and address
them in detail. The focus this month will be issues
related to skin involvement in scleroderma.
We hope you find this section informative. However,
we understand individual circumstances are unique, and
ask that you seek the guidance of your healthcare professional
to obtain the treatment plan best suited to your specific
health history.
Calcinosis
Calcinosis is a condition
that sometimes occurs in both limited (CREST) and diffuse
cutaneous systemic sclerosis. It is characterized by
calcium deposits in the soft tissue (just below the
skin's surface) of the fingers, hands, elbows, feet,
knees, or even buttocks. Diagnosis can be easily confirmed
When calcium deposits occur
in the hand or fingers, they can impair function due
to their painful nature. It is important to protect
the area in which they occur. Padding the area with
bandages can be most helpful to avoid the inevitable
bumping or banging of the area during your daily activities.
Many patients have become quite creative devising techniques
to cushion these areas. Some have found the foot-care
section of their local drug stores to be a source of
helpful products. Toecaps and tubular cushioning bandages,
commonly used for corn protection, can be a wonderful
way to protect the painful sites on your fingers.
Minimizing Calcinosis Discomfort
Unfortunately, there is no effective way to prevent
calcium deposits, but there are some therapies to minimize
the discomfort associated with their presence. Warm-water
soaks can be helpful in decreasing the inflammation
and pain. Cushioning protection as mentioned above,
and good skin care, can help to minimize breakdown of
the skin over an affected area.
In an effort to decrease inflammation associated with
calcinosis, some physicians may prescribe the medications
colchicine, low-dose warfarin, or minocycline.
It is important to note that there
is no one medication proven to be universally effective
for the treatment of calcinosis. Occasionally antibiotics
may be prescribed to treat a localized infection that
may occur in the area of the deposit. Keep in mind that
the area may be affected by inflammation of the tissue
surrounding the calcium deposit and may become reddened
as a result. It can be difficult to determine if this
is actually just inflammation or a sign of infection.
Preventing Calcinosis Infection
Even patients who are meticulous
in the care of their hands may experience a calcium
deposit that opens up at the surface of the skin, producing
a milky white material.
Extreme care should be taken to minimize infection over
this area. Soap and water cleansing, as well as sterile
bandaging to protect the open area from infection are
very important.
If you develop signs of infection
in the open area such as redness, swelling, excessive
pain, drainage, or fever, please contact your healthcare
provider immediately for treatment. In this instance
antibiotic therapy would be necessary.
In severe cases surgical removal
of the deposit may be necessary, but recurrence is common.
Never, ever, pick, dig, or probe
at a calcium deposit, no matter how great the urge to
do so, because this can lead to infection and other
serious complications. Always consult your physician
if an area is painful or swollen or shows any of the
other signs of infection outlined above.
The Sun
and Your Skin
Many persons with localized or systemic
scleroderma enjoy spending time in the sun for family
activities, or feel that it has a therapeutic effect
on their skin. Anyone who spends time in the sun should
take precautions to protect themselves from skin cancer.
A few things to keep in mind:
- ALWAYS wear
sunscreen or sunblock when exposing your skin to the
suns rays. Those of you who like to tan should remember
that you can still get a tan while wearing sunscreen.
If you have sensitive skin, you can buy sunscreen
products especially developed with you in mind. If
you are swimming or sweating, remember to reapply
sunscreen occasionally. You may also want to consider
using a product labeled waterproof or "sport."
Wearing a broad-brimmed hat can give you extra protection
from the sun's harmful rays.
- The sun
is drying to the skin. Remember to moisturize your
skin frequently with a product that contains lanolin
to minimize this effect. Dry skin may increase itchy
skin!
- Hypopigmented
(decreased color) areas of your skin as a result of
your scleroderma (this is most common in people of
color) are at greater risk of sunburn and skin cancers.
Hyperpigmented (darkened) areas may become more pronounced
with sun exposure.
Skin
Ulcerations
Quite a few patients with limited
or diffuse scleroderma will experience skin ulcerations
on their fingertips, knuckles, or creases of their fingers.
This can also occur on the toes. An open area can persist
for months, so vigilance is necessary to minimize its
impact.
Here are a few tips to help prevent ulcerations and
to care for these areas if ulcers develop.
- Prevention
is key.
- Protect
your hands from trauma. A small scratch or cut can
lead to ulceration.
- Practice
good skin care. Moisturize often, particularly after
washing hands; protect skin from cleaning detergents
by wearing gloves; avoid hot water; and never pick
or dig at calcium deposits.
- Keep warm.
It is important to keep your entire body warm, not
just your hands. During cool or cold weather, wear
layers to keep your trunk warm. Wear a hat and don't
forget proper attire for your feet. You may want to
consider the added benefit of chemical hand or toe
warmers. Always preheat your vehicle before driving.
Your hands may need protection in warm weather months
as well. Wear gloves in the grocery store if you are
prone to Raynaud attacks when exposed to colder sections
of the store such as the freezer or produce and meat
coolers. Use coozies over bottles or glasses that
contain cold beverages, or decant your beverages into
insulated cups.
- Try to minimize
stress as much as possible, or identify techniques
than can help you manage it.
- Do Not
Smoke! The nicotine in cigarettes decreases blood
flow to the fingers and toes. Second-hand smoke can
also be problematic for those with Raynaud phenomenon.
- Avoid caffeinated
beverages. Caffeine will also constrict blood vessels
decreasing blood flow to the fingers and toes.
If an open area develops, the following tips may be
helpful:
- Keep the
area warm to maximize blood flow.
- Keep the
area very clean by using bandages.
- Soapy washes
combined with topical antibiotics such as Neosporin
or Bacitracin several times a day can minimize the
risk of infection.
- Always report
any new open area on your fingers or toes to your
physician when you visit. If the area develops signs
of infection that include redness, heat, excessive
pain, drainage or you develop a fever please contact
your physician for care. An oral antibiotic and close
monitoring by your health care practitioner will be
necessary to treat the infection and manage healing.
- Pain control
is very important while managing a digital ulcer.
Uncontrolled pain can interrupt sleep, which in turn
will increase pain, etc. It is a vicious cycle and
has a huge impact upon daily life and ability to function.
Please talk honestly with your physician about your
level of pain and its impact on your life.
- Remember to take all medications
prescribed for your Raynaud's. Good wound care and
vasodilatation is the main-stay of wound management.
Itchy
Skin (Pruritis)
Itching is a common problem for
many with scleroderma. It is caused by an inflammatory
process associated with the disease. This complication
usually occurs within the first two to five years of
the disease and then will subside. For some, the problem
may persist.
Unfortunately, it can be difficult
to manage; but here are a few hints that may help you.
- Remember
to moisturize your skin regularly, particularly after
bathing. Use of a product that contains lanolin is
recommended. Dry skin can intensify the itch.
- Avoid hot
showers or baths that rob the skin of needed moisture.
- Use gentle
soaps such as Neutrogena or Dove. Non-soap cleansers
such as Cetaphil or Aveeno may also be used.
- Use a humidifier
in cold winter months to help keep skin moist.
- Experiment
with moisturizers until you find one that is compatible
with your skin type. Many patients have reported going
through several until they found the right product.
- If the above
measures are not enough to manage your pruritis, you
may want to discuss prescription options with your
physician. Antihistamines such as Benadryl and Atarax
have been helpful, as have some topical hydrocortisone
creams. Some physicians have found colchicine effective.
In severe cases, low-dose prednisone has been used.
- Try not
to scratch. Scratching can increase the itch, and
potentially cause breaks in the skin that may become
infected.
- For some,
choosing to wash clothes in a gentle detergent like
Dreft or Ivory Snow may be helpful, in addition to
avoiding fabric softeners or dryer sheets.
- Others have indicated that
100% cotton clothing is more comfortable against their
skin than blends, synthetics, or woolens.
Telangiectasia
Telangiectasias (telan-jee-eckta-zhas)
are tiny red spots caused by the dilatation (widening)
of small blood vessels in the skin. They appear as reddened
freckles on ones face or hands.
Some persons experience telangiectasias
on their lips and inside their mouths. These lesions
are benign and do not pose any danger. However, many
find them to be cosmetically unacceptable, and may choose
one of the following methods to improve their appearance
and feel better about themselves.
Over-the-Counter Products to Cover Telangiectasias
There are wonderful cosmetics available
at department stores, dermatologists' offices, or on
the Internet that very effectively conceal the affected
areas.
Two of the most popular products
reported by patients as easy to use and effective are
Dermablend corrective cosmetics and Coverblend by Neostrata.
Laser Treatment to Remove Telangiectasias
Laser treatments can effectively
remove telangiectasias for those who desire a more permanent
approach. This treatment is usually not covered by insurance
because it is viewed as cosmetic. If you consider this
procedure, always work with a dermatologist or plastic
surgeon who is board-certified and has had formal training
in the use of lasers.
It is important to note that telangiectasias
tend to recur.
In rare cases, telangiectasias can
occur in the throat or stomach and cause bleeding. This
requires immediate attention. Gastroenterologists can
successfully treat these areas with laser therapy.
Fingernails
and scleroderma
Some persons with scleroderma will
report a fingernail that appears to be separating from
the nail bed. This is called onycholysis, and can occur
due to Raynaud phenomenon or systemic disease such as
scleroderma.
Patients are advised not to trim
or push back their cuticles. However, if you decide
to do so, be very careful not to traumatize the surrounding
tissue, which could lead to a non-healing ulceration
or possibly infection.
If you visit a nail technician for
your nail care, always educate them about your scleroderma
and Raynaud phenomenon. They will need to be gentle
and vigilant so they do not nick or scratch your fingers
or toes.
The few minutes it will take to educate
the service provider can save you weeks or months of
discomfort. |
