What is scleroderma?

Scleroderma is typically described as a rheumatic disease of the connective tissues. It is a chronic, degenerative disorder accompanied by widespread vascular deterioration and tissue loss. Scleroderma can be disfiguring, debilitating and deadly. In the most serious cases, the disease causes severe damage and severe complications for the body’s digestive, respiratory and circulatory systems.

Pain, ranging in severity from uncomfortable to debilitating, is a common characteristic of the disease. Other common symptoms can include, but are not limited to the following:

  • General fatigue
  • Joint or bone aching
  • Stiffness of hands and feet
  • Skin discoloration
  • Swallowing difficulties
  • Skin thickening or tightness
  • Dry mucus membranes
  • Calcium deposits under the skin
  • Unexplained ulcers on fingers or toes
  • Raynaud’s phenomenon (described below)

Scleroderma is not a single disease, but a set of related disorders involving a similar set of symptoms. This makes a concise definition – and diagnosis – difficult. All forms of scleroderma do, however, share the basic characteristics of fibrosis (an excessive accumulation of tissue) and inflammation.

Recent research suggests that scleroderma is not only a rheumatic disease, but also has a blood vessel component. Inflammation in the body’s blood vessels leads to their narrowing. Further damage from the inflammation and impact of the increased blood pressure can lead to destruction of smaller arteries. As a result, or perhaps as a parallel disease process, fibrosis takes place. This process can have devastating implications and the heart and lungs can suffer a significant loss in efficiency. Pulmonary arterial hypertension (PAH) is the leading cause of death in scleroderma patients.

The first documented account of scleroderma was by Dr. Carlo Curzio of Naples in 1754, who described his patient as a 17-year-old Neapolitan woman afflicted by a disease of “extraordinary nature.” “Her complaint,” wrote Dr. Curzio, “was an excessive tension and hardness of her skin over all her body, by which she found herself so bound and straightened that she could hardly move her limbs.” Nor could she fully close her eyelids or open her mouth, due to “the firmness of the skin and membrane.”

The fibrosis witnessed by Dr. Curzio is the most noticeable feature of the disease. In fact, the word scleroderma is Greek for “hard skin,” although it is much more than that, often affecting the internal organs with life-threatening consequences.

Hundreds of thousands of people suffer from the various types of scleroderma, and as many as 10,000 patients die every year from the most serious form of the disease. Eighty percent of those afflicted with the disease are women, though scleroderma also strikes men and children across all ages and ethnic boundaries. Unfortunately, the disease typically strikes in the prime of patients’ lives, when they are 30-50 years old.

The cause of scleroderma is unknown. It is not contagious and it is rare for direct family members to manifest the disease. However, there is evidence of a genetic predisposition to scleroderma. Some scleroderma cases have been linked to environmental factors such as silica dust, organic solvents, and certain drugs, though the cause for most cases of scleroderma is still not known.

Significant progress has been made in managing the symptoms and some of the most serious complication of scleroderma, so that people with the disease are living longer, fuller lives. Still, no therapies yet exist to halt or reverse the disease process. Patients continue to experience pain, deterioration and debilitation – and many patients die.

The Scleroderma Research Foundation is devoting every possible resource to solving the mysteries of scleroderma. A collaborative approach to research is opening doors to therapeutic development and ultimately, a cure.

Types of scleroderma

There are two major types of scleroderma—localized and systemic. Localized scleroderma affects only the skin and is, generally, not as destructive or debilitating as systemic scleroderma, which is a multi-system disease often involving the skin, blood vessels, heart, lungs, kidneys and other major organs.

Localized sclerodermaSystemic scleroderma (systemic sclerosis)
Localized morphea Limited systemic sclerosis
Generalized morphea Diffuse systemic sclerosis
Linear scleroderma Sine sclerosis

 

Localized Scleroderma

The skin is typically the only organ involved in localized scleroderma. In extreme cases, however, the muscle below is also affected by a hardening of the tissues. Because internal organs are not affected by localized scleroderma, it is not a life-threatening illness and can be considered a less serious health threat than other forms of the disease. Symptoms of localized scleroderma will, in many cases, improve or go away on their own over time, but there is frequently permanent damage in the form of residual scar tissue. For some patients, localized scleroderma can be disfiguring and painful. In rare cases, it can be disabling. There are three major sub-types of localized scleroderma:

Localized Morphea

Morphea (mor-FEE-ah) is derived from the Greek word “morfi,” meaning shape or structure. With localized morphea, the body shows one or several patches of scleroderma. Symptoms include reddish patches of inflamed and discolored skin, usually on the chest or back, but sometimes on the face, arms and legs. These oval-shaped patches are limited to certain areas on the body and range in size from a half-inch to approximately 12 inches in diameter. Localized morphea is further pronounced by the absence of sweat glands and very little, if any, hair growth in affected areas.

Generalized Morphea

Generalized morphea is a more severe, although less common, condition than localized morphea. Large dark patches of thick, tight skin form on the trunk, arms and legs, and can be so extensive that they merge into one another. These widespread plaques closely resemble oversized patches of localized morphea, but are usually ivory-colored and sometimes have a distinct violet-colored border. Patients with generalized morphea do not suffer from the internal life-threatening features of systemic sclerosis, but the disease can result in severe scars and physical disability.

Generalized morphea has been known to appear on areas of the skin treated by radiation therapy.

In many cases, both localized and generalized morphea improve spontaneously over time (typically 3 through 5 years); however, patients are often left with patches of darkened or discolored skin and, in rare cases, muscle damage.

Linear Scleroderma

Linear scleroderma, also known as bilateral scleroderma, is characterized by a highly visible band or bands of thick, tight skin on the arms, legs, chest, stomach, back, buttocks or face. It is often considered a pediatric disease as it usually manifests itself within the first 10 years of life.

When affecting a limb, linear scleroderma can cause arms and legs to develop at noticeably different rates. It is not uncommon for the disease to extend down to the bones and muscles underneath it, thus damaging their structure, limiting motion of affected joints, and interfering with normal growth.

When linear scleroderma occurs on the face, it is often referred to as en coup de saber (en-KOO-de-sob), a French term for “a strike of the sword,” due to its appearance. Linear scleroderma may be disfiguring, but is not life threatening and rarely progresses to systemic scleroderma.

Systemic Scleroderma (Systemic Sclerosis)

Systemic scleroderma, also known as systemic sclerosis, is a multi-system disease with numerous manifestations that can affect not only the skin, but also underlying blood vessels, muscles and joints, as well as the gastrointestinal tract, kidneys, lungs and heart. There are two subsets of systemic scleroderma, limited and diffuse – both are characterized by vascular injury, as well as severe inflammation and fibrosis.

Systemic scleroderma causes a loss of circulation that can result in painful skin ulcers occurring on fingers, toes and other extremities. Joint pain caused by inflammation and swelling can be chronic. Loss of flexibility in the hands and severe skin tightening can impair the use of fingers and toes. The skin of the face may also tighten and harden, especially around the mouth, making eating and drinking difficult.

Systemic scleroderma (both limited and diffuse) is the most dangerous form of the disease and the primary focus of research funded by the Scleroderma Research Foundation.

It is estimated that approximately 90% of systemic scleroderma patients experience Raynaud’s (ray-NOHZ) phenomenon as a primary symptom. Named after the French physician who discovered it more than a century ago, Raynaud’s is a condition in which the small blood vessels of the hands and, sometimes, feet contract in response to cold or stress. The process makes the hands/feet extremely sensitive to cold and causes their pigmentation to blanch from white to blue. As blood flow returns, they become red. With scleroderma patients, tissues in fingertips, especially the capillaries, may suffer damage. This damage can lead to ulcers, scars, or, in severe cases, gangrene.

It should be noted that Raynaud’s phenomenon is quite common, affecting approximately 1 of every 20 people in the United States. Research suggests that only 5 – 20% of people with Raynaud’s phenomenon will go on to develop a form of systemic scleroderma.

Limited Scleroderma

Systemic limited scleroderma affects approximately two-thirds of the systemic population. Although the progression is typically more slow-moving, the disease can still be life-threatening. It is imperative to treat these symptoms and carefully monitor for end-organ damage. Chronic pain, loss of mobility and disfigurement are possible. There is also the potential for serious complications related to the esophagus and other parts of the gastrointestinal tract, as well as pulmonary complications leading in some cases to dangerously high blood pressure. Systemic-limited scleroderma is often referred to as CREST, an acronym for several of the most prominent symptoms:

Calcinosis Hard, painful calcium deposits in the skin
Raynaud’s phenomenon Blanching of feet and hands from white, to blue to red in response to cold or stress
Esophageal dysfunction Problems with swallowing caused by internal scarring. The scarring is caused by the collagen build-up.
Sclerodactyly Tightening of the skin on the fingers and toes, progressing to the hands and face, and sometimes the neck and feet
Telangiecstasia Small red spots on the fingers, palms, forearms, face and lips

 

Diffuse Scleroderma

Diffuse scleroderma is typically characterized by an early internal inflammatory phase. Also, unlike limited scleroderma, the onset of symptoms that significantly impact quality of life can be rapid and severe. In most cases of diffuse scleroderma, there is extensive skin fibrosis covering large parts of the body and extremities. Even cases without significant skin involvement can be life-threatening, depending on the type and magnitude of organ damage.

Problems of the digestive tract can make eating, nutrient absorption and elimination difficult. The most serious complications of diffuse scleroderma involve the kidneys, lungs and heart and may include renal failure, pulmonary arterial hypertension (PAH) and the potential for heart failure. PAH is the leading cause of death among scleroderma patients.

People with diffuse scleroderma are often chronically tired, have a diminished appetite, show weight loss, and suffer from joint swelling and pain. Changes in the skin can include swelling, tightening and chronic itchiness.

It is not uncommon for people with diffuse scleroderma to enter a phase where disease progression stabilizes for varying lengths of time. This stabilizing phase often begins within three to five years after onset and can last for varying amounts of time.

As with all forms of the disease, there is no cure for diffuse scleroderma. Although the disease may continue to lie dormant for several years, there can be no certainty as to whether symptoms will improve, remain stagnate or worsen.

Early diagnosis, symptomatic treatment and frequent visits to a physician for monitoring are critically important for diffuse scleroderma patients.

Sine Sclerosis

Sine (SEEN-ay) sclerosis is a term used by many physicians to describe systemic scleroderma without the characteristic skin involvement. In fact, the word “sine” is Latin for “without.” Patients with sine sclerosis may have symptoms of either limited or diffuse scleroderma, causing damage to the internal organs. Because there are no external manifestations of the disease, it can be difficult to diagnose. As with other forms of systemic sclerosis, however, the presence of Raynaud’s phenomenon and positive autoantibodies can be useful indicators. Complications of the internal organ systems can be serious and often life threatening.

 
 

Research News

Clinical Trial Design Issues in Systemic Sclerosis: an Update

Author: Jessica K. Gordon, Robyn T. Domsic
Date Published: May-2016
Source: Springer Link

Systemic sclerosis (scleroderma, SSc) is a multisystem disease characterized by vasculopathy, autoimmunity, and fibrosis. SSc has the highest disease-related mortality rate among the rheumatologic illnesses. In the USA, there remains no FDA-approved therapy. As our understanding of SSc pathogenesis improves, targeted therapies interrupting key pathways and mediators will be studied in clinical trials. However, clinical trials in SSc are fraught with challenges. Validated clinical outcome measures do not exist for all disease manifestations. It can be difficult to discern disease activity from damage. SSc is highly heterogeneous, with multiple different phenotypes, and predicting who will have progressive disease is not currently well understood. Biomarkers are in early stages of development and do not represent surrogate outcomes at this time.

O27 Subcutaneous Tocilizumab in Adults with Systemic Sclerosis: 24 and 48 Week Safety and Efficacy Data from the Fasscinate Trial

Author: C. Denton, D. Khanna, A. Jahreis, J. van Laar, et al
Date Published: May-2016
Source: Oxford Journals Rheumatology

Background: Interleukin-6 (IL-6) appears to play a key role in the pathogenesis of SSc, a debilitating disease with limited treatment options. Methods: A double-blind, placebo-controlled, phase 2, proof-of-concept study of the efficacy and safety of the IL-6 receptor inhibitor tocilizumab (TCZ) (weekly s.c. injection; TCZ 162 mg vs placebo for 48 weeks) in patients ≥18 years of age with active SSc. The primary end point was a mean change in the modified Rodnan skin score (mRSS) from baseline at week 24. Change in the mRSS at week 48, patient-reported outcomes (PROs) and pulmonary function (week 48) were exploratory measures.

Frequency of circulating topoisomerase-I-specific CD4 T cells predicts presence and progression of interstitial lung disease in scleroderma

Author: A. Fava, R. Cimbro, F. Wigley, Q. Liu, A. Rosen and F. Boin
Date Published: May-2016
Source: BioMed Central

Scleroderma is an antigen-driven T cell-mediated autoimmune disease. Presence of anti-topoisomerase-I antibodies is associated with pulmonary fibrosis and predicts increased mortality. Characterization of autoreactive T lymphocytes may shed light on disease pathogenesis and serve as a biomarker for disease activity. Here, we aimed to quantify and functionally characterize circulating topoisomerase I (topo-I)-specific CD4+ T cells and to define their association with presence and progression of interstitial lung disease (ILD) in patients with scleroderma.

M10, a caspase cleavage product of the hepatocyte growth factor receptor, interacts with Smad2 and demonstrates antifibrotic properties in vitro and in vivo.

Author: Atanelishvili I, Shirai Y, Akter T, Buckner T, Noguchi A, Silver RM, Bogatkevich G
Date Published: April-2016
Source: Translational Research

Hepatocyte growth factor receptor, also known as cellular mesenchymal-epithelial transition factor (c-MET, MET), is an important antifibrotic molecule that protects various tissues, including lung, from injury and fibrosis. The intracellular cytoplasmic tail of MET contains a caspase-3 recognition motif "DEVD-T" that on cleavage by caspase-3 generates a 10-amino acid peptide, TRPASFWETS, designated as "M10". M10 contains at its N-terminus the uncharged amino acid proline (P) directly after a cationic amino acid arginine (R) which favors the transport of the peptide through membranes. M10, when added to cell culture medium, remains in the cytoplasm and nuclei of cells for up to 24 hours.

Esophageal dilatation and interstitial lung disease in systemic sclerosis: a cross-sectional study

Author: C. Richardson, R. Agrawal, J. Lee, O. Almagor, R. Nelson, J. Varga, M. Cuttica, J. D′Amico Dematte, R. Chang, M. Hinchcliff,
Date Published: February-2016
Source: Science Direct

A patulous esophagus on high-resolution computed tomography (HRCT) of the thorax is frequently observed in patients with systemic sclerosis (SSc). Microaspiration has been purported to play a role in the development and progression of SSc interstitial lung disease (ILD), but studies examining the role of microaspiration in SSc-ILD have yielded conflicting results. This study was conducted to determine the association between esophageal diameter and SSc-ILD.

News for Patients

Being Disfigured by Scleroderma Gave Me the Chance to Love Myself

Author: Lisa Goodman-Helfand
Date Published: June-2016
Source: Dr. Oz, The Good Life

Nobody escapes adolescence unscarred by the agony of bullies, peer pressure, acne, and hormones. Along with every survivor of that awkward era, I, too, faced these obstacles. But I had the added bonus of navigating a newly diagnosed autoimmune disease: scleroderma.

I was 10 years old when doctors introduced me to the unknown world of scleroderma. It was 1985, long before Google could tell you every horrifying detail about your illness. I had no idea scleroderma could affect a patient externally, causing the skin to tighten and result in disfigurement and other painful physical abnormalities. Nor did I know that in its worst form, scleroderma attacks one's internal organs and can be fatal. In an effort to shield me from the complexities of scleroderma, my mom told me that my skin was tighter than normal, but that I was perfectly fine otherwise.

Scleroderma Patients and Lung Transplantation

Author: John Hansen-Flaschen, MD
Date Published: June-2016
Source: ATS News

Two studies published in the June issue of Annals of the American Thoracic Society look at scleroderma and lung transplantation. Patients with advanced lung disease due to systemic sclerosis (SSC) have long been considered poor candidates for lung transplantation. However, in a retrospective study of lung transplant outcomes over an eight-year period at the University of Pittsburgh, Maria M. Crespo. MD, and colleagues found that one- and five-year survival in patients with scleroderma are similar to pulmonary fibrosis. The results, they wrote, “indicate that lung transplant is a reasonable treatment option in selected patients with scleroderma.”

Phase 3 Trial to Begin for Terguride in Diffuse Cutaneous Scleroderma

Author: Magdalena Kegel
Date Published: June-2016
Source: Scleroderma News

The German pharmaceutical company Medac, in August, will begin Phase 3 of a clinical trial to access the therapeutic potential of terguride, a disease-modifying drug for the treatment of diffuse cutaneous systemic sclerosis.

Terguride is a serotonin receptor blocker, acting at two particular serotonin receptors called 5-HT2A and 5-HT2B. Medac is convinced that stopping the nerve signaling in serotonin neurons will block the progression of fibrotic tissue development and blood vessel remodeling in organs affected by diffuse cutaneous systemic sclerosis.

Pfizer, Novartis, BMS join $45M round for early fibrotic disease startup

Author: Stacy Lawrence
Date Published: June-2016
Source: Fierce Biotech

A trio of pharmas have bought into the early vision of startup Blade Therapeutics. Pfizer Venture Investments, Novartis Institutes for Biomedical Research and Bristol-Myers Squibb ($BMY) all came in to the $45 million Series B round for the startup, which aims to address novel targets in fibrotic disease. It expects to get into the clinic with this financing.

Founded in the fall of 2015, Blade is based upon technology in-licensed from Johns Hopkins University, in particular, on work from the lab of Dr. Harry Dietz--a professor of genetics and medicine at the university and the company’s founder. His work focuses on the cause of a pair of fibrotic diseases: Marfan Syndrome and Stiff Skin Syndrome, which forms the basis of Blade’s investigation into new biological pathways involved in tissue fibrosis and dysfunction.

Progression of Lung Fibrosis in Scleroderma May Be Predicted by Antibody-Specific T-cells

Author: Magdalena Kegel
Date Published: May-2016
Source: Scleroderma News

Immune T-cells induced by the presence of autoantibodies against topoisomerase-I were linked to lung fibrosis and found to predict disease progression in scleroderma patients. The finding may open new avenues of research into treatments that selectively target the various tissue-specific disease manifestations of scleroderma — a substantial improvement to the nonselective immunosuppression used today.

In scleroderma, autoantibodies targeting specific structures are linked to various clinical representations of the disease. One such antibody against the enzyme topoisomerase-I, crucial for the winding and unwinding of DNA molecules during gene expression and cell divisions, is present in 20 percent to 45 percent of scleroderma patients and linked to diffuse skin disease and lung fibrosis. Patients with anti-topoisomerase-I antibodies also have more severe disease.

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