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Systemic Scleroderma

Irina Alexandrovna Zborovskaya – doctor of medical sciences, professor,cathedral professor of hospital therapy with the course of clinical rheumatology of the doctors improvement faculty of Volgograd state medical university, director of the Federal Budgetary State Institution (FBSI) “Research and development institute of clinical and experimental rheumatology” of the RAMS, head of the regional Osteoporosis Center, presidium member of the Association of rheumatologists of Russia, member of the editorial boards of the magazines “Scientific and practical rheumatology” and “Modern rheumatology” Definition. Scleroderma is a systemic disease of the connective tissue characterized by generalized degenerative and sclerotic changes of the connective tissue. Occlusion of the microvasculature (for example, Raynaud’s phenomenon), progressive fibrosis of skin and other tissues, including visceral organs, and angiospastic disturbances are common features of systemic scleroderma.
Epidemiology. Scleroderma is found in all geographic locations and affects all races and ethnic groups worldwide. The incidence of scleroderma increases with age, reaching its peak in patients aged 30 – 40 years. The incidence for women is  3 times higher than for men. However, the incidence for women during childbearing years is 15 times higher than for men. The incidence of scleroderma averages 19 to 75 cases per 100,000 people. Systemic scleroderma most commonly occurs in families, in persons carrying autoantibodies and those with increased prevalence of diseases of the connective tissue. Studies have shown that a higher risk exists for HLA-DR1, HLA-DR2, HLA-DR3, HLA-DR5, HLA-DQA2 carriers and C4A gene allele. Aetiology. The exact aetiology of scleroderma is unclear. Environmental factors play a significant role in the development of systemic scleroderma. It was reported that a higher risk for developing systemic scleroderma exists for miners and builders who are exposed to silicon dust. Polyvinyl chloride exposure can also lead to the development of Raynaud`s syndrome, acroosteolysis, skin involvement and changes of the nail capillaries as well as to hepatic fibrosis and hemangiosarcoma. Exposure to epoxy resins and aromatic carbohydrates (for example, benzol and toluene) may also be a factor. Application of analgesics, such as pentazocine, can lead to pronounced fibrosis of skin and cell tissue. Administration of antitumor drugs, such as bleomycine, leads to the formation of fibrous nodes and hyperpigmentation of skin, alopecia, gangrene of fingers and pneumosclerosis. In pneumosclerosis the lower lobes of the lungs are usually the first to be involved. Pathogenesis. The vessels of the endothelium are typically the first to be involved. At an early stage of systemic scleroderma intimal hyperplasia, typically present in sclerodermal vessels, can reduce the luminal diameter causing limited blood flow. Physiologic stimuli (for example, cold, emotions, thromboxane A2, serotonin) can increase the constriction of vessels and lead to the development of Raynaud` s phenomenon in skin and internal organs. Once kidneys are affected, stimulation of renin-angiotensin mechanism leads to the constriction of vessels. At a later stage of the disease skin infiltration by activated T-lymphocytes, increased synthesis of IL-1, IL-4, IL-6 cytokines, proliferation of fibroblasts, synthesis of collagen Type 1 and 3 as well as release of platelet-derived growth factor and transforming growth factor-beta can be noted. Activation of mast cells leads to triptase synthesis which activates transforming growth factor-β. It also contributes to the production of eosinophilic cation protein and histamine which stimulates proliferation of fibroblasts and synthesis of matrix components. Development of Raynaud`s phenomenon is accounted for by complex immunologic interactions of endothelial (for example, nitrogen oxide, endothelin-1, prostaglandins) and platelet mediators (such as serotonin, beta-thromboglobulin) as well as neuropeptides such as peptide associated with calcitonin and vasoactive intestinal polypeptide. Endothelium involvement and insufficiency of tissue-type plasminogen activator contribute to intravascular coagulation and in severe cases can cause hemolytic microangiopathic anemia. Skin biopsy near the foci of sclerosis demonstrates perivascular and diffuse skin infiltration caused by T-lymphocytes and macrophages. T-lymphocytes are typically represented by T-helpers. Increased level of IL-2 cytokines, IL-2 free receptors, CD4 free molecules as well as activation of adenosine deaminase in blood serum of patients indicate activation of T-helpers. Basal membranes of vessels can be a target for cellular immune reactions which occur in this condition. Adhesion molecules contributing to interaction of T-lymphocytes with endothelium play a role in the pathogenesis of systemic scleroderma. In healthy people collagen Type VII is considered to be the main component of attachment fibrils which stabilize the link between epidermis and derma. In patients with systemic scleroderma collagen Type VII is found in the derma. That’s why the skin is thickened and connected with underlying tissues. Humoral immunity is typically impaired in patients with systemic scleroderma. 95 percent of patients have antinuclear antibodies in blood serum. Some patients have antibodies to laminin and collagen Type IV. However, the significance of auto-antibodies in pathogenesis of the disease is unclear. Classification of systemic scleroderma is presented in Table 1. Acute, subacute and chronic courses of the disease are typically singled out. In an acute course of the disease systemic scleroderma is characterized by rapid progression of both skin and internal organ lesions. Progressive renal failure, especially in the first years after the onset of the disease, typically leads to death. In a subacute course of the disease systemic scleroderma is characterised by a gradual onset. In this case skin is usually involved. It is typically associated with sclerodermatous edema and skin induration, recurrent polyarthritis, myositis with myasthenic syndrome, involvement of internal organs. Cross syndromes can also be noted. In a chronic course of the disease systemic scleroderma is characterized by progressive vasomotor disturbances such as Raynaud`s syndrome, and clearly marked trophic disturbances which may be the only finding for many years and which further typically prevail in clinical presentation. Skin and para-articular tissues become thickened leading to the development of contractures and osteolysis. Slow- progressing sclerotic changes of internal organs are also common in systemic scleroderma.
Table 1.
Classification of systemic scleroderma (suggested by Guseva N.G.,1994)  
Course of the disease Stage of development Extent of disease activity Clinical and morphologic characteristics of changes occurring in systemic scleroderma
Skin and peripheral vessels Musculo-skeletal system Heart Lungs Gastro-intestinal tract Kidneys Nervous system
Acute  Subacute Chronic I – initial  II – generalized III – terminal I (minimum)  II (moderate) III (maximum) Thickened and indurated edema, atrophy, hyperpigmen-  tation, telangiectasy, Raynaud’s syndrome, focal lesions. Arthralgia, polyarthritis (exudative or fibrous-indurative, pseudoarthri-tis, polymyositis, calcinosis, osteolysis.    Myocardosis, cardiosclero-sis, heart failure (insufficiency of mitral  valve – most commonly). Interstitial pneumonia, pneumoscle-rosis (compact or cystous), adhisive pleurisy. Esophagitis, duodenitis, colitis, spreu-like syndrome. True scleroder-mic kidney, chronic diffuse nephritis, focal nephritis. Polyneuritis, neuropsychic disturbances, vegetative shifts.
Clinical forms  I. Typical (associated with common skin lesions); II. Atypical forms: With focal lesion of skin; Predominantly visceral; Articular; Muscular; Vascular.
According to the disease activity, maximum (3rd degree), moderate (2nd degree) and minimum (1st degree) degree of disease activity are singled out.
According to the extent of disease progression, the stage of initial clinical manifestations (for example, Raynaud`s syndrome, polyarthralgia, arthritis, and less commonly skin, visceral or general manifestations), generalized or diffuse stage (characterised by numerous clinical manifestations) and terminal stage of the disease are singled out. Terminal stage is typically characterized by sclerotic, dystrophic and vascular-necrotic changes of organs associated with the disorder of their function. The following main clinical forms of systemic scleroderma are singled out:
  1. Prescleroderma
  2. Diffuse skin sclerodema
  3. Limited skin scleroderma
  4. Sclerodermia without scleroderma
  5. Cross-syndrome
Prescleroderma is characterized by the presence of Raynaud`s phenomenon and changes of the nail capillaries, digital ischemia and immunologic disturbances which are common in systemic scleroderma. Diffuse scleroderma is characterized by rapid progression of the disease and skin involvement which is proximal to radiocarpal joints, presence of antibodies to Scl-70 (antinuclear antibodies). Internal organs and especially kidneys, are involved much earlier in systemic scleroderma than in acrosclerotic scleroderma. Patients may also develop pulmonary fibrosis. Acrosclerotic or limited scleroderma is characterized by symmetric skin lesions with limited involvement of the distal parts of the extremities, face and visceral organs. It often includes CREST syndrome which is a term used to describe the main clinical manifestations of the syndrome. They are the following: subcutaneous calcinosis (skin is involved on the face and extremities), Raynaud`s syndrome, esophagitis (that is disorder of the motor function of the esophagus), sclerodactily, teleangiectasia. In patients with CREST syndrome anticentromere antibodies are typically present. Internal organs are less commonly affected and the disease typically develops very slowly. Pulmonary fibrosis or primary biliary cirrhosis can occur even after several years of the disease. Systemic Raynaud`s phenomenon is also common. It is usually characterised by generalized vasoconstriction of arteries carrying blood to kidneys, heart and other organs. Sclerodermia without scleroderma is the so-called visceral form of systemic scleroderma. In this case prognosis of the disease depends on the severity of the involvement of internal organs such as heart, lungs, kidneys. Cross syndrome or mixed disease of the connective tissue is referred to as overlap-syndrome. Overlap syndrome is considered to be a rheumatic condition which is characterised by clinical manifestations of systemic scleroderma, rheumatoid arthritis, systemic lupus erythematosus and polymyositis.  High-titred antibodies to ribonucleoproteins are typically present. This syndrome usually turns into systemic scleroderma or systemic lupus erythematosus. Clinical manifestations. 95 percent of patients eventually develop skin involvement. Changes are typically present on the fingers and hands as well as on the proximal aspects of the trunk and face. Lower extremities are less commonly affected. The following phases are singled out in cutaneous changes: early (edematous) stage. Edema may appear thick or it may form a pit or erythema when pressing. Permeability of the walls of the vessels increases and endothelium of the small vessels is impaired. The early stage is followed by an indurated stage which is characterized by increased collagen synthesis. Atrophic stage is characterized by atrophy of the skin and its appendages, dryness of skin and connection of the skin with underlying tissues. Skin changes can lead to the changes of the face expression. The face becomes mask-like and amimic. The nose and ears are thinned. The mouth is narrowed and there are wrinkles at the angles of the mouth The eyelids do not close fully. Changes of the hands are also common in systemic scleroderma. They usually develop due to edema and induration. The fingers look like as if they are made of plaster cast. It is difficult to clench fists. Most patients usually develop osteolysis and shortening of phalanges. As the disease progresses, most nail plates are dissolved. Raynaud`s phenomenon develops in 95 percent of patients. Raynaud`s phenomenon may precede obvious sclerodermatous features by months or even years. Symptoms may be not evident. Episodic spasms of the involved vessels of the fingers can cause colour changes of pallor (white), cyanosis (blue), and then redness (red) or reactive hyperemia. Vasospastic disturbances in systemic scleroderma are typically noted in hands and feet. Sometimes numbness and whitening of lips, face, and the tip of the tongue may also occur. Vasospastic disturbances can occur in internal organs (for example, in the brain, heart, lungs). Telangiectasias typically develop in skin or/and in mucous membranes. Telangiectasias are referred to as star-shaped dilated capillaries and small vessels located just beneath the dermis on any skin area. 30 percent of patients develop telangiectasia in diffuse systemic scleroderma and 80% of patients develop telangiectasia in limited systemic scleroderma. Telangiectasias are more obvious at the advanced stage of the disease. Subcutaneous calcinosis most commonly occurs on the fingers, elbows and knees; however, any area can be affected. For example, epiglottis, vocal cords, pericardium, valves and cardiac muscle, hepatic capsule and the capsule of the spleen can be affected. Skin ulceration often develops on the tips of the fingers due to impaired blood circulation. Sometimes ulcerations may occur in the area of auricles and even eye-lids. Gastrointestinal involvement occurs most commonly in systemic scleroderma. It is characterised by certain clinical and X-ray manifestations and it helps the doctor diagnose systemic scleroderma. Disorder of the motor function of the esophagus is typically due to atrophy of the smooth muscles and formation of collagen in the lower third of the esophagus. Esophageal sphincter incompetence is typically noted. Straited muscles of the upper third of the esophagus are not usually impaired. Reduced amplitude or absence of peristalsis of the lower third of the esophagus is commonly seen. It is often associated with gastroesophageal reflux disease which has the following symptoms: dysphagia, impaired swallowing, painful regurgitation, heartburn in the epigastrium and in the substernal area. Dysphagia (especially when swallowing) can occur without any other obvious symptoms of esophagus involvement. It is caused by decreased peristalsis of the esophagus due to neuromuscular disturbances. According to the extent of severity of esophagus involvement, 3 degrees of sclerodermic involvement of the esophagus, which reflect the development of the pathologic process are singled out. They are the following: 1st degree – of moderate severity; it is characterized by a slightly slowed movement of barium sulfate from the cranial to the caudal parts of the esophagus. 2nd degree – clearly marked; it is characterized by a slowed movement of barium sulfate through the esophagus as well as prolonged delay of barium in the esophagus, opening, enlargement of the lumen of the esophagus, changes of the mucous membrane surface. 3rd degree – maximum; it is characterized by a slowed movement of barium sulfate through the esophagus and prolonged delay of barium sulfate in the esophagus, clearly marked enlargement of the lumen of the esophagus, changes of the mucous membrane surface, signs of gastroesophageal reflux disease and its secondary complications. Esophagus ulcer most commonly occurs at the site of connection of the esophagus and the stomach. Sometimes it can cause bleeding from the esophagus. Along with this, gastroesophageal reflux disease can cause cylinder-cell metaplasia of the epithelium of the esophagus; however, adenocarcinoma develops quite rarely. Enlargement, atony and slowed evacuation of the stomach are common features of stomach involvement. Changes occurring in the intestine are the same as in the esophagus. Sclerodermic duodenitis is clinically manifested by the disorder of the motor function of the intestine, cramps, diarrhea and pain. Malabsorption and syndrome of bacterial growth are common in small intestine involvement. Spue-like syndrome (that is weight loss, diarrhea and anemia) is also typical of small intestine involvement. Severe constipation sometimes associated with partial recurrent intestinal obstruction and sacculation are typical of large intestine involvement. Telangiectasy of the stomach and intestine can cause gastrointestinal bleeding. Mucous membrane involvement (as in Sjegren’s syndrome) is commonly noted in systemic scleroderma. Secretory insufficiency of exocrine glands develops due to a chronic inflammatory process in the glands. Enlarged parotid glands (fibrosis), dryness of mucous membranes of the eye (xerophthalmia) and that of the mouth (xerostomia), trachea, bronchi, stomach, vagina and skin are commonly noted in systemic scleroderma. Endocrine glands are also commonly involved in systemic scleroderma. Hypothyroidism often develops due to chronic lymphocyte thyroiditis and fibrosis of the thyroid gland. Disorder of the function of the adrenal cortex, primary and secondary diabetes underlying interstitial fibrosis of the pancreas are typical of systemic scleroderma. Articular syndrome is clinically manifested in 3 main forms. They are the following: polyarthralgia; sclerodermic polyarthritis associated with either exudative-proliferative or fibrous-indurative changes; and periarthritis associated with the development of fibrous contractures. Flexion contractures typically develop due to ligament involvement and progressive thickening/ of the skin. Some patients develop osteolysis (especially of the phalages). It is caused by vascular-trophic disturbances and is clinically manifested by shortening and deformity of the toes and fingers. Resorption of distal phalanges of the hands and feet, ribs, clavicles and the angle of the lower jaw may occur. Osteolysis is not typically seen in other diseases of the connective tissue. Muscle involvement in patients with systemic scleroderma is usually of mild severity. It is typically associated with a slight increase of enzyme activity and does not usually require any specific treatment. Sometimes fibrous interstitial myositis associated with atrophy of muscle fibers may occur. Patients may present with increased muscle weakness, less commonly myalgia. Nervous system involvement is clinically manifested both by peripheral and central neuropathy. Pulmonary involvement in patients with systemic scleroderma includes: interstitial fibrosis or fibrosing alveolitis associated with the involvement of the lower lobes of the lungs; diffuse pulmonary fibrosis; involvement of the pulmonary vessels indicating the presence of pulmonary hypertension; pulmonary complications (viral and bacterial pneumonias, rupture of subpleural cysts associated with the development of pneumothorax, abscess formation, lung cancer associated with sclerodermic pneumofibrosis). Pulmonary hypertension is clinically manifested by increased breathlessness resulting in the development of tricuspid insufficiency. Survival rate in pulmonary hypertension averages 2 years. Bronchiectasis, emphysema, perifocal pneumonia, cystous pneumosclerosis typically occur in well pronounced pneumosclerosis. Pleurisy in systemic scleroderma is less common than in other rheumatic conditions. Heart involvement includes changes of the myocardium, endocardium and pericardium. At an early stage of myocardium involvement edema, inflammation and proliferation of a new loose connective tissue and sometimes areas of necrobiosis of muscle fibers can be noted. Well pronounced myocardium involvement associated with cardiosclerosis, fibrous-sclerotic scarring of the cardiac muscle is referred to as myocardosis or interstitial myocarditis. Myocardial fibrosis with a large focus can indicate infarction-like changes on routine ECGs. However, in some cases it can lead to the development of “callous” heart aneurysm. Calcinosis of certain parts of the cardiac muscle may develop. Angina pectoris may occur in fibrous impairment of coronary arteries. Endocardium involvement typically results in sclerodermic heart failure (that is calcinosis of the valves) which is characterized by a chronic course of the disease and sometimes by the development of decompensation. Mitral and tricuspid valves are most commonly affected. Pericarditis as a manifestation of polyserositis has an adhesive-exudative character and is not clearly marked. Renal involvement occurs in 80% of patients with systemic scleroderma and is characterized by the involvement of renal vessels. In true sclerodermic kidney progressive proteinuria, increased arterial blood pressure, oliguria, uremia, and terminal anuria are typically noted. Sclerodermic renal crisis usually develops in the first 5 years after the onset of the disease. It typically occurs in patients with diffuse systemic scleroderma and presents as diffuse glomerulonephritis. Progressive oliguric acute renal insufficiency develops as a result of fibrosis of interlobular arteries associated with the effect of some vasoconstrictive stimuli such as diuresis, bleeding, surgical intervention. Three degrees of chronic sclerodermic nephropathy are singled out. Minimum, subclinical chronic sclerodermic nephropathy is characterized by slight and unstable changes in urine and /or functional disturbances (reduction of glomerular filtration). Moderate chronic sclerodermic nephropathy is characterized by slight but stable changes in urine associated with dysfunction of kidneys. In clearly marked chronic sclerodermic nephropathy patients develop hypertension, edema, hyperreninemia, urinary syndrome and functional disturbances. Lab studies are usually non-specific and typically indicate the extent of disease activity and immune disturbances. Peripheral blood in systemic scleroderma does not change. However, some patients develop anemia, leukocytosis or (less commonly) leucopenia, increased ESR. Increased fibrinogen, seromucoid, alfa-2-globuline, IgG may occur. Hyperproteinemia (hypergamma-globulinemia) may be also present. Some autoantibodies can also be revealed in systemic scleroderma (Table 2). Rheumatoid factor may occur in 40 – 50 percent of patients, lupous LE-cells are present in 2 – 7 percent of patients, antinuclear factor is present in 60 – 70 percent of patients. Table 2. Autoantibodies revealed in systemic scleroderma
Autoantibodies Type of disease Detection rate, %
Antibodies to Scl-70 antigene Diffuse 40
Antibodies to centromeres Limited 60-80
Antibodies to RNA-polymerase I, II, III Diffuse 5-40
Antibodies to Th-ribonucleoproteid Limited 14
Limited 5-10
Mixed disease of the connective tissue 95-100
Antibodies to PM-1 antigen Cross-syndrome associated with clinical manifestations of polymyositis and limited type of systemic scleroderma 25
Diagnostic criteria of systemic scleroderma (suggested by Guseva N.G., 1993) Basic: Peripheral: 1. Raynaud`s syndrome 2. Sclerodermic skin involvement 3. Articular-muscular syndrome (with contractures) 4. Osteolysis 5. Calcinosis Visceral: 6. Basal pneumosclerosis 7. Cardiosclerosis with a large focus. 8. Sclerodermic gastrointestinal involvement 9. Acute sclerodermic nephropathy Lab findings: Specific AHA (anti-Scl-70 and anti-centromere antibodies) Additional: Peripheral: 1. Skin hyperemia 2. Telangiectasia 3. Trophic disturbances 4. Polyarthralgia 5. Polymyalgia, polymyositis Visceral: 6. Lymphadenopathy 7. Polyserositis (most commonly adhesive) 8. Polyneuritis, central nervous system involvement General: 1. Loss of body weight – more than 10 kg 2. Fever (most commonly subfebrile) Lab findings: 1. Increased ESR (more than 20 mm/hr); 2. Hyperproteinemia (more than 75 g/l); 3. Hypergammaglobulinemia (more than 23%); 4. Antibodies to DNA or antinuclear factor; 5. Rheumatoid factor. Differential diagnostics. Systemic scleroderma should be differentiated from other diseases of the connective tissue and conditions that have in common fibrosis of skin. Raynaud`s syndrome as well as some other vascular and visceral symptoms are not typical of  many diseases of this group. Systemic scleroderma should be differentiated from the following diseases:
  1. Rheumatoid arthritis
  2. Polymyositis (dermatomiositis) and antisynthetase syndrome
  3. Vasculitis (thromboangiitis obliterans, arteritis Takayasu); atherosclerosis
  4. Systemic lupus erythematosus
  5. Primary Sjegren’s sicca syndrome
  6. Mixed diseases of the connective tissue
  7. Diseases associated with increased blood viscosity (cryoglobulinemia, polycithemia, Waldenstrem`s macroglobulinemia)
  8. Tunnel syndromes
  9. Endocrine diseases
10. Side-effects of drug treatment with beta-adrenergic blockers, bleomycine, vinblastine, clonidine, ergotamine 11. Pseudosclerodermic syndrome (changes occurring in pseudosclerodermic syndrome are the same as in systemic scleroderma; however, they are considered to be secondary and develop due to a malignant tumour) 12. Focal sclerodermia (morphea, morphea linearis) 13. Eosinophilic fasciitis 14. Eosinophilic myalgia syndrome 15. Verner`s syndrome 16. Bushke`s syndrome 17. Arndt-Gottron scleromyxedema 18. Hereditary hemorrhagic teleangiectasia, Rendu-Osler-Weber disease. Treatment of systemic scleroderma. Treatment of systemic scleroderma is a very difficult task which has not been solved yet. It should be undertaken considering the stage and the course of the disease. The main priciples of treatment are the following:
  1. Prevention and treatment of vascular complications
  2. Control of fibrosis progression
  3. Effecting the main immuno-inflammatory mechanisms of systemic scleroderma
  4. Prevention and treatment of internal organ involvement
D-penicillamine is considered to be effective in treating systemic scleroderma as it inhibits excessive fibrosis, helps limit collagen formation, prevents formation of intramolecular and intermolecular sutures in collagen fibers. D-penicillamine is prescribed in the dose of 450 – 900 mg daily. The dose should be increased every 2 weeks by 300 mg. It may be increased to 1500 mg if necessary. D-penicillamine should be used for approximately 1, 5 – 2 months before one decides on efficacy. The maintenance dose of D-penicillamine (that is 300 – 450 mg daily 1 hour before meals or 2 hours after meals) is typically administered. The treatment with D-penicillamine should be quite prolonged and it should take several years. Nowadays 125 – 500 mg of D-penicillamine every twenty-four hours before meals is considered to be beneficial. Application of 50% dimexide solution to the damaged skin increases permeability of the tissues and inhibits proliferation of fibroblasts. It is effective when added to vasodilatating drugs as it helps penetrate them through the skin. Lidase or hyaluronidase is administered in a chronic course of systemic scleroderma or in focal scleroderma as a repeated course. Methotrexate is reported to be effective in treating systemic scleroderma. Studies demonstrate its superiority in patients with skin, joint and muscle involvement (7, 5 – 10 mg weekly). Recombinant gamma-interferon and alfa-interferon obstructs the development of fibrosis. Extracorporal photochemotherapy helps decrease skin manifestations. Hygienic procedures also play an important role. Washing with soft cleaners (without soap), having a bath with various oils and  using hydrophilic creams and ointments helps decrease dryness of skin. Daily physical exercises and massage help preserve the range of motion of the extremities and make the skin more elastic. To accelerate the process of healing of uninfected ulcers on the tips of the fingers, they should be washed and treated regularly and necrotic tissues should be removed with the help of enzymatic agents. Ulcers heal better if sympatholytics are used. If ulcers are infected, local antimicrobial treatment is typically administered. Sometimes, however, with suspicion of osteomyelitis, systemic antimicrobial drugs should be used. No drugs which prevent calcification of the skin and contribute to absorption of calcificates exist. However, the number of calcificates in some patients decrease considerably due to the use of warfarin and dilthiazem. The main indications for the administration of corticosteroids are the following:
  1. High activity of sclerodermic process
  2. Well pronounced immune shifts
Prednisolone in the dose of 20 – 30 mg daily is used until the therapeutic effect is achieved and then the dose should be gradually reduced to a maintenance one (that is 15 – 10-5 mg). However, in fibrosing alveolitis it is increased to 40 mg daily, in polymyositis – to 50 – 60 mg daily. It has been shown that oral cyclophosphamid in the dose of 2 – 2.5 mg daily (that is intramuscular cyclophosphamid in the dose of 200 – 400 ml per week) combined with low doses of prednisolone improved the pulmonary function in patients with systemic scleroderma and pulmonary fibrosis. However, it should be stressed that no therapies exist for scleroderma in patients with pulmonary involvement. In renal involvement the use of corticosteroids should be differentiated. Steroid therapy cannot be used in acute sclerodermic kidney associated with hypertension and progressive uremia. The use of glucocorticoids more than 15 – 20 mg daily increases the risk for developing normotensive renal crisis. Angiotensin-converting enzyme inhibitors should be administered as early as possible after the appearance of the first symptoms of renal involvement. They are considered to be effective due to high concentration of renin in systemic scleroderma. Angiotensin-converting enzyme inhibitors should be combined with calcium-ion blockers and disaggregants in treating acute sclerodermic nephropathy. Plasmapheresis, glucocorticoids and cytotoxic drugs are contraindicated as they don`t prevent the progression of renal involvement. They contribute to an exacerbation of the process. In Raynaud`s syndrome the patients should be instructed to avoid cold exposure, smoking, stress, vibration, excessive caffeine and some drugs which induce vasoconstriction such as ergotamine, amphetamine and beta-adrenergic blockers. Placebo-controlled studies demonstrated the efficacy of calcium channel blockers. Raynaud`s syndrome can be treated with amlodipine in the dose of 5 – 20 mg daily; felodipine – 2.5 – 10 mg twice a day; isradipine 2.5 – 5.0 mg twice a day; nifedipine prolonged 30 – 120 mg daily; dilthiazem prolonged 120 – 300 mg daily; verapamil 120 – 360 mg daily. Serotonin receptor blockers such as ketanserin 80 – 120 mg daily, fluoxetine 20 – 40 mg daily, and some other vasodilating drugs, including nitroglycerine ointment, can also be used. Placebo-controlled studies demonstrated the efficacy of angiotensin II receptor antagonist (lozartan 25 – 100 mg daily). As the substances released by platelets damage the walls of the vessels, disaggregants such as pentoxyphilline, dipiridamol and rheopoliglucine can be used in the treatment of systemic scleroderma. However, a 2-year study with the help of double blind method did not demonstrate their efficacy. The use of prostaglandins and their synthetic analogues in treating vascular involvement has not been studied yet. Vasaprostane, alprostadile, prostavazine belong to PG1 (prostaglandin 1) group. Vasaprostane has a well pronounced peripheral vasodilating action. It increases blood flow in peripheral vessels, improves microcirculation and rheological features of the blood, slows down aggregation of platelets and has a disaggregating action. Iloprost is a synthetic analogue of prostacycline. However, this drug has not been studied yet. In gastroesophageal reflux disease the patient should be instructed about a diet. Histamine-receptor H2-blockers such as ranitidine, famotidine are typically used when vascular peripheral syndrome is associated with esophagitis and ulcer changes in the gastrointestinal tract. Proton pump inhibitors such as omeprazole, lansoprazole, rabeprazole are effective in suppressing gastric secretion and in erosive esophagitis. In articular syndrome nonsteroidal anti-inflammatory drugs, corticosteroids are beneficial. They are typically used when there are other indications for the use of steroids. Quinoline drugs are typically used in treating systemic scleroderma. The treatment is usually prolonged and it is used in combination with other drugs. Massage, remedial exercises and physiotherapy should be advised to the patient if there are no any contraindications. Prognosis. The course of systemic scleroderma varies greatly. It is very difficult to evaluate the prognosis at an early stage of the disease when the differences between its two forms are  unclear. In acrosclerotic (limited) scleroderma, especially when anticentromere antibodies are present, the prognosis is quite favorable. Pulmonary hypertension usually occurs in 10 percent of patients. Sometimes malabsorption and primary biliary hepatic cirrhosis may develop. In diffuse systemic scleroderma the prognosis is much worse, especially in men and in the elderly. Pulmonary, renal and cardiovascular involvement are the main causes of death. 10-year survival rate in systemic scleroderma is 65 percent, in diffuse scleroderma – 55 percent and in limited scleroderma – 75 percent.