Children with scleroderma: Treating and living with skin ulcers
Written by Thomas J.A. Lehman, Pediatric Rheumatologist
Chronic skin ulcers are one of the most
discouraging problems for children with scleroderma. They hurt
at even the slightest touch and sometimes it seems nothing will
get rid of them. Fortunately, however, that’s not true. Skin
ulcers can be treated and with luck they can be gotten rid of.
Even if you can’t get rid of them completely there are a number
of tricks for making the problem better. The most important
thing is to understand where they come from.
Skin ulcers most often appear over the knees
or elbows, around the ankles, or on the tips of the fingers.
These areas all have several common attributes. They are all
places where the skin is relatively thin in that there isn’t a
lot of tissue underneath it. This means the blood supply is
relatively poor (even though they certainly can bleed). In
addition they are areas that are frequently bumped or otherwise
injured. It is this combination of poor blood supply and
repeated injury that leads to the development of ulcers. In
children with scleroderma we can directly attack both of those
The poor blood supply to the skin is the
direct result of the scleroderma itself. Scleroderma damages
the blood vessels and decreases blood flow. To improve this we
must treat the scleroderma. I have had my best success in
treating children with methotrexate. This often results in
dramatic softening of the skin and healing of the ulcers.
Methotrexate also has a direct anti-inflammatory effect which
helps to control the ulcers. In children with milder disease
where methotrexate isn’t necessary blood flow to the skin can be
improved by using drugs which open up the blood vessels. These
are the same drugs that we use for Raynaud’s. Some doctors like
nifedipine, others isradipine, and still others amlodipine. All
of them work for some people and none works for everyone. There
are also many reports that pentoxifylline is effective (I like
it, but not everyone agrees). Newer reports suggest that
sildenafil and agents like that may also work by increasing
blood flow. These medications all have to be prescribed by your
physician and each may have side effects which you need to be
Medications to improve the blood supply are an
important part of caring for skin ulcers, but they aren’t the
whole answer. Skin ulcers are poorly healing areas which have
been injured. If you can prevent the injury you can prevent the
ulcers. Unfortunately it only takes the tinniest of injury to
start ulcers in some people. Just the two ankles knocking into
each other while walking might be enough. If a child is ulcer
prone everyone needs to take steps to minimize the trauma. That
means being careful of injuries to the fingers. That may mean
wearing elbow pads or knee pads. It can mean wrapping the
ankles with moleskin or other soft protective materials. In
addition it means that parents and children must be constantly
vigilant for any areas of skin irritation or redness that
suggest an area may break down. Careful preventive measures and
steps to keep the skin soft and improve blood flow to the area
may be enough to stop an ulcer from developing. I have my
patients use a lot of cocoa butter on dry cracked areas. Gentle
massage can keep the skin soft and improve blood flow preventing
problems from getting worse.
Once an ulcer is present all of the above
steps to protect the area become even more important. However
ulcer’s need air to heal. Don’t cover them with protective
materials. Anyone with an obvious skin ulcer needs to be under
the care of an experienced physician who is paying careful
attention. Infected ulcers can be catastrophic. Minor ulcers
often respond to local measures. Keep the area clean, dry and
warm to improve blood flow. Topical antibiotics may help, but
different doctors have different ideas. Avoid trauma to the
area and avoid getting it wet unless it is being soaked in
antibiotic containing solution. There are a variety of
prescription coverings that contain moisturizing agents and
antibiotics, but you’ll need to get these from an experienced
wound healing specialist.
The best answer. Prevent the problem whenever
possible. Keep the disease under good control. Watch
vulnerable areas and take steps to protect them. Respond
immediately to any area that looks at risk. Good luck!!
Please keep in mind, this webpage is for your information only.
Please check with your child's physician for any treatments.
For more information on Juvenile Scleroderma, contact:
Juvenile Scleroderma Network, Inc.
1204 W. 13th Street, San Pedro, CA 90731
Tel: (310)519-9511 (Pacific Time)
Speak to another JSD parent for emotional and logistical support
provided by home-based JSD volunteers. For medical advice, please
contact your child's physician.
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