Handout on Health: Scleroderma
This booklet is for people who have scleroderma, as well as for their family members, friends, and others who want to find out more about the disease. This booklet describes the different forms of scleroderma and provides information on their symptoms, diagnosis, and treatment, including what patients can do to help manage their disease and the problems associated with it. It also highlights current research efforts into the understanding and treatment of scleroderma, many of which are supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes of Health (NIH). If you have further questions after reading this booklet, you may wish to discuss them with your doctor.
What Is Scleroderma?
Derived from the Greek words “sklerosis,” meaning hardness, and “derma,” meaning skin, scleroderma literally means hard skin. Though it is often referred to as if it were a single disease, scleroderma is really a symptom of a group of diseases that involve the abnormal growth of connective tissue, which supports the skin and internal organs. It is sometimes used, therefore, as an umbrella term for these disorders. In some forms of scleroderma, hard, tight skin is the extent of this abnormal process. In other forms, however, the problem goes much deeper, affecting blood vessels and internal organs, such as the heart, lungs, and kidneys.
Scleroderma is called both a rheumatic (roo-MA-tik) disease and a connective tissue disease. The term rheumatic disease refers to a group of conditions characterized by inflammation and/or pain in the muscles, joints, or fibrous tissue. A connective tissue disease is one that affects the major substances in the skin, tendons, and bones.
In this booklet we’ll discuss the forms of scleroderma and the problems with each of them as well as diagnosis and disease management. We’ll also take a look at what research is telling us about their possible causes and most effective treatments, and ways to help people with scleroderma live longer, healthier, and more productive lives.
What Are the Different Types of Scleroderma?
The group of diseases we call scleroderma falls into two main classes: localized scleroderma and systemic sclerosis. (Localized diseases affect only certain parts of the body; systemic diseases can affect the whole body.) Both groups include subgroups. (See chart.) Although there are different ways these groups and subgroups may be broken down or referred to (and your doctor may use different terms from what you see here), the following is a common way of classifying these diseases:
- Localized Scleroderma: Localized types of scleroderma are those limited to the skin and related tissues and, in some cases, the muscle below. Internal organs are not affected by localized scleroderma, and localized scleroderma can never progress to the systemic form of the disease. Often, localized conditions improve or go away on their own over time, but the skin changes and damage that occur when the disease is active can be permanent. For some people, localized scleroderma is serious and disabling.There are two generally recognized types of localized scleroderma:
- Morphea: Morphea (mor-FEE-ah) comes from a Greek word that means “form” or “structure.” The word refers to local patches of scleroderma. The first signs of the disease are reddish patches of skin that thicken into firm, oval-shaped areas. The center of each patch becomes ivory colored with violet borders. These patches sweat very little and have little hair growth. Patches appear most often on the chest, stomach, and back. Sometimes they appear on the face, arms, and legs.Morphea can be either localized or generalized. Localized morphea limits itself to one or several patches, ranging in size from a half-inch to 12 inches in diameter. The condition sometimes appears on areas treated by radiation therapy. Some people have both morphea and linear scleroderma (described below). The disease is referred to as generalized morphea when the skin patches become very hard and dark and spread over larger areas of the body.Regardless of the type, morphea generally fades out in 3 to 5 years; however, people are often left with darkened skin patches and, in rare cases, muscle weakness.
- Linear scleroderma: As suggested by its name, the disease has a single line or band of thickened and/or abnormally colored skin. Usually, the line runs down an arm or leg, but in some people it runs down the forehead. People sometimes use the French term en coup de sabre, or “sword stroke,” to describe this highly visible line.
- Systemic Scleroderma (also known as Systemic Sclerosis): Systemic scleroderma, or systemic sclerosis, is the term for the disease that not only includes the skin, but also involves the tissues beneath to the blood vessels and major organs. Systemic sclerosis is typically broken down into diffuse and limited disease. People with systemic sclerosis often have all or some of the symptoms that some doctors call CREST, which stands for the following:
- Calcinosis (KAL-sin-OH-sis): the formation of calcium deposits in the connective tissues, which can be detected by x ray. They are typically found on the fingers, hands, face, and trunk and on the skin above elbows and knees. When the deposits break through the skin, painful ulcers can result.
- Raynaud’s (ray-NOHZ) phenomenon: a condition in which the small blood vessels of the hands and/or feet contract in response to cold or anxiety. As the vessels contract, the hands or feet turn white and cold, then blue. As blood flow returns, they become red. Fingertip tissues may suffer damage, leading to ulcers, scars, or gangrene.
- Esophageal (eh-SOFF-uh-GEE-ul) dysfunction: impaired function of the esophagus (the tube connecting the throat and the stomach) that occurs when smooth muscles in the esophagus lose normal movement. In the upper esophagus, the result can be swallowing difficulties; in the lower esophagus, the problem can cause chronic heartburn or inflammation.
- Sclerodactyly (SKLER-oh-DAK-till-ee): thick and tight skin on the fingers, resulting from deposits of excess collagen within skin layers. The condition makes it harder to bend or straighten the fingers. The skin may also appear shiny and darkened, with hair loss.
- Telangiectasias (tel-AN-jee-ek-TAY-zee-uhs): small red spots on the hands and face that are caused by the swelling of tiny blood vessels. While not painful, these red spots can create cosmetic problems.
- Limited Scleroderma: Limited scleroderma typically comes on gradually and affects the skin only in certain areas: the fingers, hands, face, lower arms, and legs. Many people with limited disease have Raynaud’s phenomenon for years before skin thickening starts. Others start out with skin problems over much of the body, which improves over time, leaving only the face and hands with tight, thickened skin. Telangiectasias and calcinosis often follow. Because of the predominance of CREST in people with limited disease, some doctors refer to limited disease as the CREST syndrome.
- Diffuse Scleroderma: Diffuse scleroderma typically comes on suddenly. Skin thickening occurs quickly and over much of the body, affecting the hands, face, upper arms, upper legs, chest, and stomach in a symmetrical fashion (for example, if one arm or one side of the trunk is affected, the other is also affected). Some people may have more area of their skin affected than others. Internally, it can damage key organs such as the heart, lungs, and kidneys.
People with diffuse disease are often tired, lose appetite and weight, and have joint swelling and/or pain. Skin changes can cause the skin to swell, appear shiny, and feel tight and itchy.
The damage of diffuse scleroderma typically occurs over a few years. After the first 3 to 5 years, people with diffuse disease often enter a stable phase lasting for varying lengths of time. During this phase, skin thickness and appearance stay about the same. Damage to internal organs progresses little, if at all. Symptoms also subside: joint pain eases, fatigue lessens, and appetite returns.
Gradually, however, the skin starts to change again. Less collagen is made and the body seems to get rid of the excess collagen. This process, called “softening,” tends to occur in reverse order of the thickening process: the last areas thickened are the first to begin softening. Some patients’ skin returns to a somewhat normal state, while other patients are left with thin, fragile skin without hair or sweat glands. More serious damage to heart, lungs, or kidneys is unlikely to occur unless previous damage leads to more advanced deterioration.
People with diffuse scleroderma face the most serious long-term outlook if they develop severe kidney, lung, digestive, or heart problems. Fortunately, less than one-third of patients with diffuse disease develop these problems. Early diagnosis and continual and careful monitoring are important.
- Sine Scleroderma: Some doctors break systemic sclerosis down into a third subset called systemic sclerosis sine (SEEN-ay, Latin for “without”) scleroderma. Sine may resemble either limited or diffuse systemic sclerosis, causing changes in the lungs, kidneys, and blood vessels. However, there is one key difference between sine and other forms of systemic sclerosis: it does not affect the skin.
What Causes Scleroderma?
Although scientists don’t know exactly what causes scleroderma, they are certain that people cannot catch it from or transmit it to others. Studies of twins suggest it is also not inherited. Scientists suspect that scleroderma comes from several factors that may include:
- Abnormal immune or inflammatory activity: Like many other rheumatic disorders, scleroderma is believed to be an autoimmune disease. An autoimmune disease is one in which the immune system, for unknown reasons, turns against one’s own body.In scleroderma, the immune system is thought to stimulate cells called fibroblasts to produce too much collagen. In scleroderma, collagen forms thick connective tissue that builds up around the cells of the skin and internal organs. In milder forms, the effects of this buildup are limited to the skin and blood vessels. In more serious forms, it also can interfere with normal functioning of skin, blood vessels, joints, and internal organs.
- Genetic makeup: While genes seem to put certain people at risk for scleroderma and play a role in its course, the disease is not passed from parent to child like some genetic diseases.However, some research suggests that having children may increase a woman’s risk of scleroderma. Scientists have learned that when a woman is pregnant, cells from her baby can pass through the placenta, enter her blood stream, and linger in her body–in some cases, for many years after the child’s birth. Recently, scientists have found fetal cells from pregnancies of years past in the skin lesions of some women with scleroderma. They think that these cells, which are different from the woman’s own cells, may either begin an immune reaction to the woman’s own tissues or trigger a response by the woman’s immune system to rid her body of those cells. Either way, the woman’s healthy tissues may be damaged in the process. Further studies are needed to find out if fetal cells play a role in the disease.
- Environmental triggers: Research suggests that exposure to some environmental factors may trigger the disease in people who are genetically predisposed to it. Suspected triggers include viral infections, certain adhesive and coating materials, and organic solvents such as vinyl chloride or trichloroethylene. In the past, some people believed that silicone breast implants might have been a factor in developing connective tissue diseases such as scleroderma. But several studies have not shown evidence of a connection.
- Hormones: By the middle to late childbearing years (ages 30 to 55), women develop scleroderma at a rate 7 to 12 times higher than men. Because of female predominance at this and all ages, scientists suspect that something distinctly feminine, such as the hormone estrogen, plays a role in the disease. So far, the role of estrogen or other female hormones has not been proven.
Who Gets Scleroderma?
Although scleroderma is more common in women, the disease also occurs in men and children. It affects people of all races and ethnic groups. However, there are some patterns by disease type. For example:
- Localized forms of scleroderma are more common in people of European descent than in African Americans.
- Morphea usually appears between the ages of 20 and 40.
- Linear scleroderma usually occurs in children or teenagers.
- Systemic scleroderma, whether limited or diffuse, typically occurs in people from 30 to 50 years old. It affects more women of African American than European descent.
Because scleroderma can be hard to diagnose and it overlaps with or resembles other diseases, scientists can only estimate how many cases there actually are. Estimates for the number of people in the United States with systemic sclerosis range from 40,000 to 165,000. By contrast, a survey that included all scleroderma-related disorders, including Raynaud’s phenomenon, suggested a number between 250,000 and 992,500.
For some people, scleroderma (particularly the localized forms) is fairly mild and resolves with time. But for others, living with the disease and its effects day to day has a significant impact on their quality of life.
How Can Scleroderma Affect My Life?
Having a chronic disease can affect almost every aspect of your life, from family relationships to holding a job. For people with scleroderma, there may be other concerns about appearance or even the ability to dress, bathe, or handle the most basic daily tasks. Here are some areas in which scleroderma could intrude.
- Appearance and self-esteem: Aside from the initial concerns about health and longevity, one of the first fears people with scleroderma have is how the disease will affect their appearance. Thick, hardened skin can be difficult to accept, particularly on the face. Systemic scleroderma may result in facial changes that eventually cause the opening to the mouth to become smaller and the upper lip to virtually disappear. Linear scleroderma may leave its mark on the forehead. Although these problems can’t always be prevented, their effects may be minimized with proper treatment and skin care. Special cosmetics–and in some cases, plastic surgery–can help conceal scleroderma’s damage.
- Caring for yourself: Tight, hard connective tissue in the hands can make it difficult to do what were once simple tasks, such as brushing your teeth and hair, pouring a cup of coffee, using a knife and fork, unlocking a door, or buttoning a jacket. If you have trouble using your hands, consult an occupational therapist, who can recommend new ways of doing things or devices to make tasks easier. Devices as simple as Velcro
- fasteners and built-up brush handles can help you be more independent.
- Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
- Family relationships: Spouses, children, parents, and siblings may have trouble understanding why you don’t have the energy to keep house, drive to soccer practice, prepare meals, and hold a job the way you used to. If your condition isn’t that visible, they may even suggest you are just being lazy. On the other hand, they may be overly concerned and eager to help you, not allowing you to do the things you are able to do or giving up their own interests and activities to be with you. It’s important to learn as much about your form of the disease as you can and share any information you have with your family. Involving them in counseling or a support group may also help them better understand the disease and how they can help you.
- Sexual relations: Sexual relationships can be affected when systemic scleroderma enters the picture. For men, the disease’s effects on the blood vessels can lead to problems achieving an erection. In women, damage to the moisture-producing glands can cause vaginal dryness that makes intercourse painful. People of either sex may find they have difficulty moving the way they once did. They may be self-conscious about their appearance or afraid that their sexual partner will no longer find them attractive. With communication between partners, good medical care, and perhaps counseling, many of these changes can be overcome or at least worked around.
- Pregnancy and childbearing: In the past, women with systemic scleroderma were often advised not to have children. But thanks to better medical treatments and a better understanding of the disease itself, that advice is changing. (Pregnancy, for example, is not likely to be a problem for women with localized scleroderma.) Although blood vessel involvement in the placenta may cause babies of women with systemic scleroderma to be born early, many women with the disease can have safe pregnancies and healthy babies if they follow some precautions.One of the most important pieces of advice is to wait a few years after the disease starts before attempting a pregnancy. During the first 3 years you are at the highest risk of developing severe problems of the heart, lungs, or kidneys that could be harmful to you and your unborn baby.If you haven’t developed organ problems within 3 years of the disease’s onset, chances are you won’t, and pregnancy should be safe. But it is important to have both your disease and your pregnancy monitored regularly. You’ll probably need to stay in close touch with the doctor you typically see for your scleroderma as well as an obstetrician experienced in guiding high-risk pregnancies.
How Is Scleroderma Diagnosed?
Depending on your particular symptoms, a diagnosis of scleroderma may be made by a general internist, a dermatologist (a doctor who specializes in treating diseases of the skin, hair, and nails), an orthopaedist (a doctor who treats bone and joint disorders), a pulmonologist (lung specialist), or a rheumatologist (a doctor specializing in treatment of rheumatic diseases). A diagnosis of scleroderma is based largely on the medical history and findings from the physical exam. To make a diagnosis, your doctor will ask you a lot of questions about what has happened to you over time and about any symptoms you may be experiencing. Are you having a problem with heartburn or swallowing? Are you often tired or achy? Do your hands turn white in response to anxiety or cold temperatures?
Once your doctor has taken a thorough medical history, he or she will perform a physical exam. Finding one or more of the following factors can help the doctor diagnose a certain form of scleroderma:
- Changed skin appearance and texture, including swollen fingers and hands and tight skin around the hands, face, mouth, or elsewhere.
- Calcium deposits developing under the skin.
- Changes in the tiny blood vessels (capillaries) at the base of the fingernails.
- Thickened skin patches.
Finally, your doctor may order lab tests to help confirm a suspected diagnosis. At least two proteins, called antibodies, are commonly found in the blood of people with scleroderma:
- Antitopoisomerase-1 or Anti-Scl-70 antibodies appear in the blood of up to 40 percent of people with diffuse systemic sclerosis.
- Anticentromere antibodies are found in the blood of as many as 90 percent of people with limited systemic sclerosis. A number of other scleroderma-specific antibodies can occur in people with scleroderma, although less frequently. When present, however, they are helpful in clinical diagnosis.
Because not all people with scleroderma have these antibodies and because not all people with the antibodies have scleroderma, lab test results alone cannot confirm the diagnosis.
In some cases, your doctor may order a skin biopsy (the surgical removal of a small sample of skin for microscopic examination) to aid in or help confirm a diagnosis. However, skin biopsies, too, have their limitations: biopsy results cannot distinguish between localized and systemic disease, for example.
Diagnosing scleroderma is easiest when a person has typical symptoms and rapid skin thickening. In other cases, a diagnosis may take months, or even years, as the disease unfolds and reveals itself and as the doctor is able to rule out some other potential causes of the symptoms. In some cases, a diagnosis is never made, because the symptoms that prompted the visit to the doctor go away on their own.
What Other Conditions Can Look Like Scleroderma?
Symptoms similar to those seen in scleroderma can occur with a number of other diseases. Here are some of the most common scleroderma lookalikes:
- Eosinophilic fasciitis (EF) (EE-oh-SIN-oh-FIL-ik fa-shi-EYE-tis): a disease that involves the fascia (FA-shuh), the thin connective tissue around the muscles, particularly those of the forearms, arms, legs, and trunk. EF causes the muscles to become encased in collagen, the fibrous protein that makes up tissue such as the skin and tendons. Permanent shortening of the muscles and tendons, called contractures, may develop, sometimes causing disfigurement and problems with joint motion and function. EF may begin after hard physical exertion. The disease usually fades away after several years, but people sometimes have relapses. Although the upper layers of the skin are not thickened in EF, the thickened fascia may cause the skin to look somewhat like the tight, hard skin of scleroderma. A skin biopsy easily distinguishes between the two.
- Undifferentiated connective tissue disease (UCTD): a diagnosis for patients who have some signs and symptoms of various related diseases, but not enough symptoms of any one disease to make a definite diagnosis. In other words, their condition hasn’t “differentiated” into a particular connective tissue disease. In time, UCTD can go in one of three directions: it can change into a systemic disease such as systemic sclerosis, systemic lupus erythematosus, or rheumatoid arthritis; it can remain undifferentiated; or it can improve spontaneously.
- Overlap syndromes: a disease combination in which patients have symptoms and lab findings characteristic of two or more conditions.
At other times, symptoms resembling those of scleroderma can be the result of an unrelated disease or condition. For example:
- Skin thickening on the fingers and hands also appears with diabetes, mycosis fungoides, amyloidosis, and adult celiac disease. It can also result from hand trauma.
- Generalized skin thickening may occur with scleromyxedema, graft-versus-host disease, porphyria cutanea tarda, and human adjuvant disease.
- Internal organ damage, similar to that seen in systemic sclerosis, may instead be related to primary pulmonary hypertension, idiopathic pulmonary fibrosis, or collagenous colitis.
- Raynaud’s phenomenon also appears with atherosclerosis or systemic lupus erythematosus or in the absence of underlying disease.
An explanation of most of these other diseases is beyond the scope of this booklet (for brief definitions, see the glossary). What’s important to understand, however, is that scleroderma isn’t always easy to diagnose; it may take time for you and your doctor to establish a diagnosis. And while having a definite diagnosis may be helpful, knowing the precise form of your disease is not needed to receive proper treatment.
How Is Scleroderma Treated?
Because scleroderma can affect many different organs and organ systems, you may have several different doctors involved in your care. Typically, care will be managed by a rheumatologist, a specialist who treats people with diseases of the joints, bones, muscles, and immune system. Your rheumatologist may refer you to other specialists, depending on the specific problems you are having: for example, a dermatologist for the treatment of skin symptoms, a nephrologist for kidney complications, a cardiologist for heart complications, a gastroenterologist for problems of the digestive tract, and a pulmonary specialist for lung involvement.
In addition to doctors, professionals like nurse practitioners, physician assistants, physical or occupational therapists, psychologists, and social workers may play a role in your care. Dentists, orthodontists, and even speech therapists can treat oral complications that arise from thickening of tissues in and around the mouth and on the face.
Currently, there is no treatment that controls or stops the underlying problem–the overproduction of collagen–in all forms of scleroderma. Thus, treatment and management focus on relieving symptoms and limiting damage. Your treatment will depend on the particular problems you are having. Some treatments will be prescribed or given by your physician. Others are things you can do on your own.
Here are some of the potential problems that can occur in systemic scleroderma and the medical and nonmedical treatments for them. (These problems do not occur as a result or complication of localized scleroderma.)
[Note: This is not a complete listing of problems or their treatments. Different people experience different problems with scleroderma and not all treatments work equally well for all people. Work with your doctor to find the best treatment for your specific symptoms.]
- Raynaud’s phenomenon: One of the most common problems associated with scleroderma, Raynaud’s phenomenon can be uncomfortable and can lead to painful skin ulcers on the fingertips. Smoking makes the condition worse. The following measures may make you more comfortable and help prevent problems:
- Don’t smoke! Smoking narrows the blood vessels even more and makes Raynaud’s phenomenon worse.
- Dress warmly, with special attention to hands and feet. Dress in layers and try to stay indoors during cold weather.
- Use biofeedback (to control various body processes that are not normally thought of as being under conscious control) and relaxation exercises.
- For severe cases, speak to your doctor about prescribing drugs called calcium channel blockers, such as nifedipine (Procardia), which can open up small blood vessels and improve circulation. Other drugs are in development and may become available in the future.
- If Raynaud’s leads to skin sores or ulcers, increasing your dose of calcium channel blockers (under the direction of your doctor ONLY) may help. You can also protect skin ulcers from further injury or infection by applying nitroglycerine paste or antibiotic cream. Severe ulcerations on the fingertips can be treated with bioengineered skin.
More than 70 percent of people with scleroderma first notice this problem when their fingers turn cold or blue, typically in response to cold temperatures or emotional distress. Raynaud’s phenomenon, as the condition is called, may precede scleroderma by years. In many people, however, Raynaud’s phenomenon is unrelated to scleroderma, but may signal damage to the blood vessels supplying the hands arising from such conditions as occupational injuries (from using jackhammers, for example), trauma, excessive smoking, circulatory problems, and drug use or exposure to toxic substances. For some people, cold fingers (and toes) are the extent of the problem and are little more than a nuisance. For others, the condition can worsen and lead to puffy fingers, finger ulcers, and other complications that require aggressive treatment.
Stiff, painful joints: In diffuse systemic sclerosis, hand joints can stiffen because of hardened skin around the joints or inflammation of the joints themselves. Other joints can also become stiff and swollen. The following may help:
Skin problems: When too much collagen builds up in the skin, it crowds out sweat and oil glands, causing the skin to become dry and stiff. If your skin is affected, you may need to see a dermatologist. To ease dry skin, try the following:
- Exercise regularly. Ask your doctor or physical therapist about an exercise plan that will help you increase and maintain range of motion in affected joints. Swimming can help maintain muscle strength, flexibility, and joint mobility.
- Use acetaminophen or an over-the-counter or prescription nonsteroidal anti-inflammatory drug, as recommended by your doctor, to help relieve joint or muscle pain. If pain is severe, speak to a rheumatologist about the possibility of prescription-strength drugs to ease pain and inflammation.
- Learn to do things in a new way. A physical or occupational therapist can help you learn to perform daily tasks, such as lifting and carrying objects or opening doors, in ways that will put less stress on tender joints.
Dry mouth and dental problems: Dental problems are common in people with scleroderma for a number of reasons: tightening facial skin can make the mouth opening smaller and narrower, which makes it hard to care for teeth; dry mouth due to salivary gland damage speeds up tooth decay; and damage to connective tissues in the mouth can lead to loose teeth. You can avoid tooth and gum problems in several ways:
- Apply oil-based creams and lotions frequently, and always right after bathing.
- Apply sunscreen before you venture outdoors, to protect against further damage by the sun’s rays.
- Use humidifiers to moisten the air in your home in colder winter climates. (Clean humidifiers often to stop bacteria from growing in the water.)
- Avoid very hot baths and showers, as hot water dries the skin.
- Avoid harsh soaps, household cleaners, and caustic chemicals, if at all possible. If that’s not possible, be sure to wear rubber gloves when you use such products.
- Exercise regularly. Exercise, especially swimming, stimulates blood circulation to affected areas.
Gastrointestinal (GI) problems: Systemic sclerosis can affect any part of the digestive system. As a result, you may experience problems such as heartburn, difficulty swallowing, early satiety (the feeling of being full after you’ve barely started eating), or intestinal complaints such as diarrhea, constipation, and gas. In cases where the intestines are damaged, your body may have difficulty absorbing nutrients from food. Although GI problems are diverse, here are some things that might help at least some of the problems you have:
- Brush and floss your teeth regularly. (If hand pain and stiffness make this difficult, consult your doctor or an occupational therapist about specially made toothbrush handles and devices to make flossing easier.)
- Have regular dental checkups. Contact your dentist immediately if you experience mouth sores, mouth pain, or loose teeth.
- If decay is a problem, ask your dentist about fluoride rinses or prescription toothpastes that remineralize and harden tooth enamel.
- Consult a physical therapist about facial exercises to help keep your mouth and face more flexible.
- Keep your mouth moist by drinking plenty of water, sucking ice chips, using sugarless gum and hard candy, and avoiding mouthwashes with alcohol. If dry mouth still bothers you, ask your doctor about a saliva substitute or a prescription medication called pilocarpine hydrochloride (Salagen) that can stimulate the flow of saliva.
Lung damage: About 10 to 15 percent of people with systemic sclerosis develop severe lung disease, which comes in two forms: pulmonary fibrosis (hardening or scarring of lung tissue because of excess collagen) and pulmonary hypertension (high blood pressure in the artery that carries blood from the heart to the lungs). Treatment for the two conditions is different.
- Eat small, frequent meals.
- Raise the head of your bed with blocks, and stand or sit for at least an hour (preferably two or three) after eating to keep stomach contents from backing up into the esophagus.
- Avoid late-night meals, spicy or fatty foods, and alcohol and caffeine, which can aggravate GI distress.
- Chew foods well and eat moist, soft foods. If you have difficulty swallowing or if your body doesn’t absorb nutrients properly, your doctor may prescribe a special diet.
- Ask your doctor about prescription medications for problems such as diarrhea, constipation, and heartburn. Some drugs called proton pump inhibitors are highly effective against heartburn. Oral antibiotics may stop bacterial overgrowth in the bowel that can be a cause of diarrhea in some people with systemic sclerosis.
Heart problems: About 15 to 20 percent of people with systemic sclerosis develop heart problems, including scarring and weakening of the heart (cardiomyopathy), inflamed heart muscle (myocarditis), and abnormal heart beat (arrhythmia). All of these problems can be treated. Treatment ranges from drugs to surgery, and varies depending on the nature of the condition.
Kidney problems: About 15 to 20 percent of people with diffuse systemic sclerosis develop severe kidney problems, including loss of kidney function. Because uncontrolled high blood pressure can quickly lead to kidney failure, it’s important that you take measures to minimize the problem. Things you can do:
- Pulmonary fibrosis may be treated with drugs that suppress the immune system such as cyclophosphamide (Cytoxan) or azathioprine (Imuran), along with low doses of corticosteroids.
- Pulmonary hypertension may be treated with drugs that dilate the blood vessels such as prostacyclin (Iloprost).
- Regardless of the problem or its treatment, your role in the treatment process is essentially the same. To minimize lung complications, work closely with your medical team. Do the following:
- Watch for signs of lung disease, including fatigue, shortness of breath or difficulty breathing, and swollen feet. Report these symptoms to your doctor.
- Have your lungs closely checked, using standard lung-function tests, during the early stages of skin thickening. These tests, which can find problems at the earliest and most treatable stages, are needed because lung damage can occur even before you notice any symptoms.
- Get regular flu and pneumonia vaccines as recommended by your doctor. Contracting either illness could be dangerous for a person with lung disease.
Cosmetic problems: Even if scleroderma doesn’t cause any lasting physical disability, its effects on the skin’s appearance–particularly on the face–can take their toll on your self-esteem. Fortunately, there are procedures to correct some of the cosmetic problems scleroderma causes.
- Check your blood pressure regularly and, if you find it to be high, call your doctor right away.
- If you have kidney problems, take your prescribed medications faithfully. In the past two decades, drugs known as ACE (angiotensin-converting enzyme) inhibitors, including captopril (Capoten), enalapril (Vasotec), and quinapril (Accupril), have made scleroderma-related kidney failure a less-threatening problem than it was in the past. But for these drugs to work, you must take them.
- The appearance of telangiectasias, small red spots on the hands and face caused by swelling of tiny blood vessels beneath the skin, may be lessened or even eliminated with the use of guided lasers.
- Facial changes of localized scleroderma, such as the en coup de sabre that may run down the forehead in people with linear scleroderma, may be corrected through cosmetic surgery. (However, such surgery is not appropriate for areas of the skin where the disease is active.)
How Can I Play a Role in My Health Care?
Although your doctors direct your treatment, you are the one who must take your medicine regularly, follow your doctor’s advice, and report any problems promptly. In other words, the relationship between you and your doctors is a partnership, and you are the most important partner. Here’s what you can do to make the most of this important role:
- Get educated: Knowledge is your best defense against this disease. Learn as much as you can about scleroderma, both for your own benefit and to educate the people in your support network (see below).
- Seek support: Recruit family members, friends, and coworkers to build a support network. This network will help you get through difficult times: when you are in pain; when you feel angry, sad, or afraid; when you’re depressed. Also, look for a scleroderma support group in your community by calling a national scleroderma organization. (See National Resources for Scleroderma, below) If you can’t find a support group, you might want to consider organizing one.
- Assemble a health care team: You and your doctors will lead the team. Other members may include physical and occupational therapists, a psychologist or social worker, a dentist, and a pharmacist.
- Be patient: Understand that a final diagnosis can be difficult and may take a long time. Find a doctor with experience treating people with systemic and localized scleroderma. Then, even if you don’t yet have a diagnosis, you will get understanding and the right treatment for your symptoms.
- Speak up: When you have problems or notice changes in your condition, don’t feel too self-conscious to speak up during your appointment or even call your doctor or another member of your health care team. No problem is too small to inquire about, and early treatment for any problem can make the disease more manageable for you and your health care team.
- Don’t accept depression: While it’s understandable that a person with a chronic illness like scleroderma would become depressed, don’t accept depression as a normal consequence of your condition. If depression makes it hard for you to function well, don’t hesitate to ask your health care team for help. You may benefit from speaking with a psychologist or social worker or from using one of the effective medications on the market.
- Learn coping skills: Skills like meditation, calming exercises, and relaxation techniques may help you cope with emotional difficulties as well as help relieve pain and fatigue. Ask a member of your health care team to teach you these skills or to refer you to someone who can.
- Ask the experts: If you have problems doing daily activities, from brushing your hair and teeth to driving your car, consult an occupational or physical therapist. They have more helpful hints and devices than you can probably imagine. Social workers can often help resolve financial and insurance matters.
Is Research Close to Finding a Cure?
No one can say for sure when–or if–a cure will be found. But research is providing the next best thing: better ways to treat symptoms, prevent organ damage, and improve the quality of life for people with scleroderma. In the past two decades, multidisciplinary research has also provided new clues to understanding the disease, which is an important step toward prevention or cure.
Leading the way in funding for this research is the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH). Other sources of funding for scleroderma research include pharmaceutical companies and organizations such as the Scleroderma Foundation, the Scleroderma Research Foundation, and the Arthritis Foundation. Scientists at universities and medical centers throughout the United States conduct much of this research.
Studies of the immune system, genetics, cell biology, and molecular biology have helped reveal the causes of scleroderma, improve existing treatment, and create entirely new treatment approaches.
Research advances in recent years that have led to a better understanding of and/or treatment for the diseases include:
- The use of a hormone produced in pregnancy to soften skin lesions. Early studies suggest relaxin, a hormone that helps a woman’s body to stretch to meet the demands of a growing pregnancy and delivery, may soften the connective tissues of women with scleroderma. The hormone is believed to work by blocking fibrosis, or the development of fibrous tissue between the body’s cells.
- Finding a gene associated with scleroderma in Oklahoma Choctaw Native Americans. Scientists believe the gene, which codes for a protein called fibrillin-1, may put people at risk for the disease.
- The use of the drug Iloprost for pulmonary hypertension. This drug has increased the quality of life and life expectancy for people with this dangerous form of lung damage.
- The use of the drug cyclophosphamide (Cytoxan) for lung fibrosis. One recent study suggested that treating lung problems early with this immunosuppressive drug may help prevent further damage and increase chances of survival.
- The increased use of ACE inhibitors for scleroderma-related kidney problems. For the past two decades, ACE inhibitors have greatly reduced the risk of kidney failure in people with scleroderma. Now there is evidence that use of ACE inhibitors can actually heal the kidneys of people on dialysis for scleroderma-related kidney failure. As many as half of people who continue ACE inhibitors while on dialysis may be able to go off dialysis in 12 to 18 months.
Other studies are examining the following:
- Changes in the tiny blood vessels of people with scleroderma. By studying these changes, scientists hope to find the cause of cold sensitivity in Raynaud’s phenomenon and how to control the problem.
- Immune system changes (and particularly how those changes affect the lungs) in people with early diffuse systemic sclerosis.
- The role of blood vessel malfunction, cell death, and autoimmunity in scleroderma.
- Skin changes in laboratory mice in which a genetic defect prevents the breakdown of collagen, leading to thick skin and patchy hair loss. Scientists hope that by studying these mice, they can answer many questions about skin changes in scleroderma.
- The effectiveness of various treatments, including (1) methotrexate, a drug commonly used for rheumatoid arthritis and some other inflammatory forms of arthritis; (2) collagen peptides administered orally; (3) halofugione, a drug that inhibits the synthesis of type I collagen, which is the primary component of connective tissue; (4) ultraviolet light therapy for localized forms of scleroderma; and (5) stem cell transfusions, a form of bone marrow transplant that uses a patient’s own cells, for early diffuse systemic sclerosis.
Scleroderma research continues to advance as scientists and doctors learn more about how the disease develops and its underlying mechanisms.
Recently, the NIAMS funded a Specialized Center of Research (SCOR) in scleroderma at the University of Texas-Houston. SCOR scientists are conducting laboratory and clinical research on the disease. The SCOR approach allows researchers to translate basic science findings quickly into improved treatment and patient care.
More Questions? Count on More Answers!
Scleroderma poses a series of challenges for both patients and their health care teams. The good news is that scientists, doctors, and other health care professionals continue to find new answers–ways to make earlier diagnoses and manage disease better. In addition, active patient support groups share with, care for, and educate each other. The impact of all of this activity is that people with scleroderma do much better and remain active far longer than they did 20 or 30 years ago. As for tomorrow, patients and the medical community will continue to push for longer, healthier, and more active lives for people with the diseases collectively known as scleroderma.
Phototherapy & Scleroderma: Phototherapy (PUVA, Narrow band or broad band UVB) is useful when larger body areas are affected by scleroderma (www.aocd.org/skin/dermatologic_diseases/ctcl.html). If the doctor thinks that phototherapy may be useful to treat the symptoms of scleroderma (mycosis fungoides), he or she will use the minimum exposure necessary and monitor the skin carefully.
The Daavlin Company is a manufacturer and distributor of phototherapy equipment in UVA, Narrow Band UVB and Broad Band UVB and combinations of these. Information is available for patients looking to acquire a unit for home use and also for dermatologists seeking to buy for their clinic environment. We would also be happy to direct you to a physician that specializes in the treatment of scleroderma with UV light.
National Resources for Scleroderma
National Institute of Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (226-4267) (free of charge)
TTY: (301) 565-2966
Fax: (301) 718-6366
This clearinghouse, a public service sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), provides information about various forms of arthritis and rheumatic diseases. The clearinghouse distributes patient and professional education materials and also refers people to other sources of information.
American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL 60168-4014
This national professional association for dermatologists publishes a pamphlet on skin conditions and can also provide physician referrals.
American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Fax: (404) 633-1870
This association provides referrals to doctors and health professionals who work on arthritis, rheumatic diseases, and related conditions. The association also provides educational materials and guidelines.
12 Kent Way, #101
Byfield, MA 01922
(800) 722-HOPE (free of charge) or (978) 463-5843
Fax: (978) 463-5809
This voluntary organization publishes information on scleroderma and funds research. It also offers patient education seminars, support groups, physician referrals, and information hotlines.
Scleroderma Research Foundation
220 Montgomery Street, Suite 1411
San Francisco, CA 94104
Phone: 415-834-9444 or
800-441-CURE (2873) (free of charge)
The Foundation’s goal is to find a cure for scleroderma by funding and facilitating the most promising, highest quality research and by placing the disease in the public eye. The Foundation distributes patient handbooks and a quarterly newsletter.
1330 West Peachtree Street
Atlanta, GA 30309
Call your local chapter (listed in the telephone directory), or (404) 872-7100 or (800) 283-7800 (free of charge)
The foundation is a major voluntary organization devoted to supporting research on arthritis and other rheumatic diseases, such as scleroderma. It also provides up-to-date information on treatments, nutrition, alternative therapies, and self-management strategies. Chapters nationwide offer exercise programs, classes, support groups, physician referral services, and free literature.
Adult celiac disease–A chronic nutritional disorder in which the body cannot effectively digest fats and wheat gluten. The condition, which results in a distended abdomen and loose, fatty stools, is associated with several autoimmune diseases.
Amyloidosis–A disease in which excessive protein is deposited around cells in various organs and tissues of the body.
Antibodies–Special proteins produced by the body’s immune system. They recognize and help fight infectious agents, such as bacteria and other foreign substances that invade the body. The presence of certain antibodies in the blood can help in making a diagnosis of some diseases, including some forms of scleroderma.
Atherosclerosis–Abnormal fatty deposits in the inner layers of large or medium-sized arteries, which can lead to hardening and narrowing of the arteries and blockages of the blood supply, especially to the heart.
Autoimmune disease–A disease in which the body’s immune system turns against and damages the body’s own tissues.
Calcinosis–The buildup of calcium deposits in the tissues. It may occur under the skin of the fingers, arms, feet, and knees, causing pain and infection if the calcium deposits pierce the surface of the skin.
Calcium channel blockers–Medicines that lower blood pressure, relieve chest pain, and stabilize normal heart rhythms by inhibiting calcium movement into the heart muscles and smooth muscle cells. They are used to treat a variety of conditions and to prevent circulatory and kidney problems in scleroderma.
Colitis–An inflammatory disease of the large intestine that results in diarrhea, discharge of mucus and blood, cramping, and abdominal pain. It is characterized by swelling, inflammation, and ulceration of the mucous membrane of the intestine.
Collagen–A fabric-like material of fibrous threads that is a key component of the body’s connective tissues. In scleroderma, too much collagen is produced or it is produced in the wrong places, causing stiff and inflamed skin, blood vessels, and internal organs.
Connective tissue–Tissues such as skin, tendons, and cartilage that support and hold body parts together. The chief component of connective tissue is collagen.
CREST syndrome–An acronym for a collection of symptoms that occur to some degree in all people with systemic sclerosis. The symptoms are Calcinosis, Raynaud’s phenomenon, Esophageal dysfunction, Sclerodactyly, and Telangiectasia. Because of the predominance of CREST symptoms in people with limited systemic sclerosis, some people use the term CREST syndrome when referring to that form of the disease.
Eosinophilic fasciitis–A scleroderma-like disorder (often considered to be a localized form of scleroderma) featuring inflammation of the fascia (the thin, sheet-like connective tissues surrounding the muscles and other body structures) and an abnormally high number of a specific kind of white blood cells (eosinophils). The result of the inflammation may be fibrous buildup in the skin of arms and legs, contractures, and carpal tunnel syndrome.
Esophageal dysfunction–Improper functioning of the esophagus (the tube that attaches the throat to the stomach) that can lead to heartburn and swallowing problems.
Fibroblast–A type of cell in connective tissue that secretes proteins, including collagen.
Fibrosis–A condition marked by increased fibrous tissue that develops between the cells of various organs or tissues. It is a common feature of scleroderma and some other diseases. Fibrosis causes hardening or stiffening of tissues in the skin, joints, and internal organs.
Graft–versus-host disease-A major complication of bone marrow transplantations and sometimes blood transfusions in which white blood cells, called lymphocytes, in the marrow or blood attack tissues in the body into which they were transplanted.
Human adjuvant disease–An autoimmune syndrome in which the body becomes extremely sensitive to a foreign material injected into the body.
Mycosis fungoides–A form of lymph cancer characterized by scaly skin patches. It progresses over several years to form elevated skin lesions and then tumors.
Pulmonary fibrosis–Hardening or scarring of lung tissue because of excess collagen. Pulmonary fibrosis occurs in a small percentage of people with systemic sclerosis.
Pulmonary hypertension–Abnormally high blood pressure in the arteries supplying the lungs that may be caused by a number of factors, including damage from fibrosis.
Raynaud’s phenomenon–A disorder of the small blood vessels of the extremities, causing coldness and reduced blood flow. In response to cold or anxiety, these vessels go into spasms, causing pain, the sensations of burning and tingling, and color changes.
Rheumatic–An adjective used to describe a group of conditions characterized by inflammation or pain in the muscles, joints, and fibrous tissue. Rheumatic diseases or disorders can be related to autoimmunity or other causes.
Sclerodactyly–The hard, shiny appearance of fingers caused by excess connective tissue buildup. This is a common feature of scleroderma, but it may also occur in other conditions.
Systemic condition–A condition involving the body as a whole, as opposed to limited conditions that affect particular parts of the body.
Systemic lupus erythematosus–A systemic rheumatic disease that occurs predominantly in women and is characterized by autoimmune activity, a facial rash across the bridge of the nose and cheeks, Raynaud’s phenomenon, joint pain and swelling, fever, chest pain, hair loss, and other symptoms. Many of its symptoms overlap with those of scleroderma.
Telangiectasia–Small red dots, usually on the face and hands, resulting from tiny blood vessels showing through the skin’s surface.
Acknowledgments The NIAMS gratefully acknowledges the assistance of Reva Lawrence, M.P.H., Susana Serrate-Sztein, M.D., Alan Moshell, M.D., and Barbara Mittleman, M.D., NIAMS, NIH; Stanley Pillemer, M.D., National Institute of Dental and Craniofacial Research; Philip Clements, M.D., University of California at Los Angeles; Vincent Falanga, M.D., Boston University; E. Carwile LeRoy, Medical University of South Carolina, Charleston; Morris Reichlen, M.D., Oklahoma Medical Research Foundation, Oklahoma City; Larry Solomon, M.D., Lutheran General Children’s Hospital, Park Ridge, IL; Virginia Steen, M.D., Georgetown University Medical Center, Washington, DC; Barbara White, M.D., University of Maryland at Baltimore; and the Scleroderma Foundation, Byfield, MA, in the preparation and review of this manuscript. Special thanks also go to the patients who reviewed this publication and provided valuable assistance. Mary Anne Dunkin was the primary author of this booklet.
The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on the progress of research in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS Web site at www.niams.nih.gov.