What is scleroderma?
The word ‘scleroderma’ means ‘hard skin’. However, many people with scleroderma have problems not only with their skin but with other parts of their bodies as well. This is the reason why it has a second name, ‘systemic sclerosis’.
Scleroderma is an uncommon, chronic (persistent) disease. It affects the connective tissues which surround the joints, blood vessels and internal organs beneath the affected area of skin.
Women are affected three to four times more often than men. The disease usually starts between the ages of 25 and 50. It only occasionally begins in children or in the elderly.
Although there is no cure, proper treatment and care can make it possible for people with scleroderma to lead full, productive lives. There may however be some limitation on your activity.
This booklet gives some basic facts about scleroderma. It discusses possible causes, the tests that are undertaken to see if you have the condition, and the range of treatments that are available, and gives addresses of organisations that may be helpful. The better informed you are, the more able you will be to take an active part with your doctor and other health workers in keeping the illness under control.
What are the two types of scleroderma?
There are two major types of scleroderma:
- Localised scleroderma (sometimes called ‘morphoea’) In this condition changes only occur in isolated areas of the skin and the tissues beneath it. It is relatively mild and does not affect internal organs.
- Systemic sclerosis With this condition changes may occur in the skin and also in a number of internal organs. These might include blood vessels, joints, the digestive system (oesophagus, stomach and bowel), and occasionally the lungs, heart, kidneys and muscles. Changes in the connective tissue may affect the function of any of these organs.
Scleroderma differs from person to person. It is hard to predict how the disease will develop in each individual. But it usually affects only a few parts of the body, and it often stabilises after a few years. How badly affected you are depends on which organs are affected. People who have the localised disease do not develop generalised scleroderma.
What is the cause of scleroderma?
The cause of scleroderma is unknown. It is not contagious and it is not passed on directly from one generation to another. However, as is the case with many other diseases, some families seem more likely to get it than others.
The connective tissue cells of people who have scleroderma produce too much of a protein called collagen. Collagen is essential for holding the body together, but if there is too much the body becomes stiff and is unable to function properly.
The small blood vessels are also damaged in scleroderma. There may be a link between the build-up of excess collagen and blood vessel changes. The excess collagen is like scar tissue. It causes thickening and stiffening of those parts of the body it affects.
The immune system may be important in causing collagen to be deposited. It occasionally seems to be triggered by some unusual chemical exposure. Scleroderma is probably caused by a combination of different genetic and environmental factors. The Arthritis Research Campaign (arc) is funding research into this.
How does it start and what effects does it have?
Scleroderma is a variable, slow, and long-term disorder. It usually starts slowly, gradually gets worse over a few years, and then stabilises. Sometimes it progresses faster. Occasionally it seems to cure itself. Its severity and effects vary. However, severe disability with scleroderma is uncommon.
An early symptom of scleroderma is an extreme sensitivity to cold, called Raynaud’s phenomenon. In Raynaud’s phenomenon the blood vessels constrict or narrow. Sometimes all it takes to trigger this response is for the person to walk into a cold room or to reach into the refrigerator. The narrowing of the blood vessels causes the blood supply to be greatly reduced; fingers and toes turn white and then blue. Often numbness and tingling are felt in the fingers and toes. When the blood vessels open again blood starts to flow, the skin colour returns to normal, and the hands become warm. Most people with Raynaud’s do not get scleroderma, but most of those with scleroderma have Raynaud’s at some stage in their illness.
Another common early symptom of scleroderma is swelling of the hands and feet, especially in the morning. The skin of the fingers and toes may look and feel swollen. It might get shiny and the usual skin creases may disappear. The facial skin may seem stiff. About 95% of people who have scleroderma have some thickening and hardening of the skin, especially of the hands, arms and face. In later stages of the disease the pads on the fingers may become thinned. Finger ulcers sometimes happen as a result of the narrowing of the small blood vessels. Some people will also develop small, white calcium deposits in various parts of the body. Scleroderma can also cause inflammation of the joints. This may be accompanied by pain, stiffness, swelling, warmth and tenderness. Muscle weakness is sometimes an early symptom of scleroderma.
Contractures (when a joint tightens into a bent position) may occur because of the tightening of the skin and the tissues surrounding the joints. Contractures may take place in the fingers and elsewhere in the body.
The disease may also affect the connective tissue of the internal organs. For example, if the digestive system is involved the muscles in the oesophagus (the tube which leads from your mouth to your stomach) may become weak. Swallowing is affected so that it is difficult to get food down into the stomach. Heartburn can be a frequent problem. Sometimes the middle and lower bowel are affected and bowel function is disturbed.
The lungs, heart and kidney are occasionally involved in scleroderma. Your doctor will be on the lookout for high blood pressure, which might indicate kidney problems.
What tests will be done?
There is no single test for scleroderma. A number of laboratory tests and other studies may be needed to help find out if you have scleroderma, and what parts of the body are affected. Tests may need to be repeated at regular intervals in order to monitor your disease.
Tests might include blood samples, x-rays, breathing tests, a heart scan (echo) and a skin biopsy (in which a small piece of skin is removed and examined under a microscope).
Scleroderma is a complicated disease, and differs in its effects on different people. Therefore it may be necessary for the doctor to see you regularly. If you are severely affected you may have to spend some time in hospital while tests are performed and special treatment is given.
What is the treatment?
There is no wonder drug or miracle cure for scleroderma. Treatment consists of exercise, care of the skin, and various drugs to help control the condition or treat complications.
Exercise and joint protection
An exercise programme is one of the most important activities to minimise the effects of the disease. Regular exercise helps keep the skin flexible, reduces contractures of the fingers and keeps the blood flowing freely. Gentle exercises are needed to keep the affected joints moving. The only time that rest helps is if joints become inflamed. Lightweight splints may help give temporary protection to joints, or help reduce contractures.
Physiotherapists and occupational therapists can help teach you an exercise programme and advise on the best ways of protecting your skin and joints. If your joints are not working properly there are many ways in which they can help these as well.
Skin care and warmth
The aim is to keep a good supply of blood flowing to the skin to protect it from cracking, peeling and ulcerating.
Keeping warm from top to toe helps open the blood vessels to the arms, hands, legs and feet; these are often the coldest parts in chilly weather. Remember to wear a hat, as a great deal of body heat is lost from an uncovered head. You might consider thermal clothing, hand-warmers, and electrically-heated gloves and socks. Dressings can protect painful or broken skin. Ask your nurse for advice about all these items.
In order to keep the skin as supple as possible, avoid using strong detergents or other substances that irritate your skin. Many brands of soap, creams and bath oils are designed to prevent dry skin. Try some of these until you find the ones that give you the best results. If you smoke it would be sensible to stop, as smoking reduces the blood flow to your skin.
Remember, some drugs work for some people and not for others. What someone else is taking may not be right for you.
To treat Raynaud’s phenomenon, drugs that cause the blood vessels to dilate or become larger are prescribed. There are several of these. They may be given by mouth, applied to the skin, or injected into a vein.
To soften the skin, several anti-fibrotic or anti-collagen drugs may be tried. Fibrosis is the formation of excessive fibrous tissue and these drugs are intended to help prevent this. However, they do not always produce a great deal of benefit.
To prevent heartburn, the doctor may recommend antacids or a drug to lower the production of acid in the stomach.
If your joints are inflamed a number of different drugs may be used to relieve pain and reduce inflammation. Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) might be used in this case. (See arc leaflet ‘Non-Steroidal Anti-Inflammatory Drugs’.)
High blood pressure sometimes occurs, but may cause no visible signs. It needs treating to prevent problems later. Several drugs are available to control your blood pressure. In particular, you may be given a drug called an ACE inhibitor.
Steroids, which are synthetic forms of a hormone (cortisone) that occurs naturally in the body, also reduce pain and inflammation. These are sometimes used (sparingly) at various stages of the disease: for example, at the early puffy stage, or if there is muscle or lung involvement. (See arc leaflet ‘Steroid Tablets’.)
There is no evidence that diet either causes, or has much effect on, scleroderma. However, the disease can cause you to lose weight, and some people have trouble with swallowing or with heartburn. Try to have balanced meals and try to stay at your normal weight. If you have trouble swallowing you should eat slowly and chew thoroughly. Drinking water or some other liquid will soften food. Eating several small meals is also a good idea. If you are having problems with eating try six small meals a day rather than three large ones. Antacids can give you ‘between meals’ relief from heartburn. If possible, try to have your largest meal in the middle of the day rather than close to bedtime.
Another suggestion if you have heartburn is to try raising the head of your bed by putting 6-inch (15 cm) blocks (or several telephone directories) under that end. In this way, gravity will stop acid from washing back from your stomach up into your oesophagus while you sleep.
Some associated problems
There may be emotional and social difficulties connected with having a long-term disease. There may be times when you feel overwhelmed by the problems. In addition, stress can affect the disease – particularly Raynaud’s phenomenon – because it reduces blood flow to some parts of the body.
You may find that the appearance and shape of your face and hands change, and find this distressing, but it is important to try to avoid undue tension. Do try and talk about any problems or feelings of stress you may have with your family and friends.
If you need help in handling stress or depression your doctor may be able to treat you or refer you to a social worker or counsellor.
Problems with containers
If you have difficulty opening child-proof medicine containers you can ask the pharmacist to dispense your drugs in a more suitable alternative. Contact arc for a special request card to be handed to your pharmacist with your prescription.
Most people with this illness are still able to lead rewarding lives. There is a good chance that you will be able to keep up most of your normal activities.
Many things can be done to alleviate the disease. While most are not dramatic, they can often make the difference between continuing a stable, well-adjusted and active life or becoming disabled. Most important is your own determination not to let it get the better of you and to have a common-sense approach to treatment.
Scientific exploration into the causes, treatment, and possible cure of scleroderma is being carried out at many centres throughout the country. arc plays a major role in funding this research.