Practical Approaches to Treatment: Case Studies

Abstract

In a patient with scleroderma (SSc) and Raynaud’s alone without digital ischemic events, the goal is not to eliminate every Raynaud’s event but to reduce the risk of ischemic ulcers or tissue loss and to improve quality of life. In patients with recurrent digital ulcers who have not responded to enhanced vasodilator therapy, we move to intravenous prostacyclin. In the USA we use epoprostenol and in Europe iloprost is available. If acute digital ischemia and no correctable lesion are discovered and prostacyclin therapy is not available or prostacyclin is not quickly reversing signs of ischemia, then a digital sympathectomy is recommended. When a patient presents with a toe ulcer, macrovascular disease should be suspected; if the peripheral pules are absent or not easily felt then further assessment is always required and a combined medical and surgical approach is often required. In a case of vasculitis early intervention treating the underlying disease to prevent further vascular damage is most important. At the same time, associated vasospasm can be a major component of vasculitis that should not be ignored.