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Vol. 18. Issue 4.
Pages 246-248 (April 2022)
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Vol. 18. Issue 4.
Pages 246-248 (April 2022)
Case Report
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Treatment of Raynaud phenomenon and ischemic ulcers associated to systemic sclerosis with hyperbaric oxygen
Tratamiento con oxígeno hiperbárico en el fenómeno de Raynaud y las úlceras digitales asociadas a esclerosis sistémicas
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María Ahijón-Lanaa,
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mahilan@mde.es

Corresponding author.
, Elia Baragaño-Ordóñezb, Raúl Veiga-Cabelloa, Carmen de la Cruz-Tapidora, Patricia E. Carreirac
a Servicio de Reumatología, Hospital Universitario Central de la Defensa Gómez Ulla, Madrid, Spain
b Servicio de Medicina Subacuática e Hiperbárica, Hospital Universitario Central de la Defensa Gómez Ulla, Madrid, Spain
c Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Table 1. Clinical characteristics of the four cases.
Abstract

We describe 4 patients with Raynaud’s phenomenon associated with systemic sclerosis, 3 with ischaemic ulcers, successfully treated with hyperbaric oxygen. This therapy has been useful in the treatment of chronic wounds due to its anti-inflammatory, antimicrobial and angiogenic effects. Hyperbaric oxygen treatment could be a therapeutic option in patients with Raynaud’s phenomenon refractory to conventional treatment.

Keywords:
Systemic sclerosis
Hyperbaric oxygen
Raynaud’s phenomenon
Digital ulcers
Resumen


Presentamos 4 pacientes con fenómeno de Raynaud asociado a esclerosis sistémica, 3 de ellos con úlceras isquémicas, con intolerancia o falta de respuesta a tratamiento convencional, que presentaron mejoría tras tratamiento con oxígeno hiperbárico. Esta terapia ha sido utilizada para el tratamiento de úlceras de diversa etiología debido a su efecto cicatrizante, angiogénico, antiinflamatorio y antimicrobiano. El oxígeno hiperbárico podría constituir una alternativa terapéutica en pacientes con fenómeno de Raynaud o úlceras isquémicas de difícil manejo.

Palabras clave:
Esclerosis sistémica
Oxígeno hiperbárico
Fenómeno de Raynaud
Úlceras digitales
Full Text
Introduction

Raynaud’s phenomenon (RP) is characterised by reversible episodes of vasospasm in acral areas (mainly fingers and toes) triggered by a physical or emotional stimulus1. RF is called secondary when it occurs in the context of another disease; it is sometimes present in different connective tissue diseases, such as systemic lupus erythematosus or systemic sclerosis. These patients may develop ischaemic digital ulcers, which significantly affect their prognosis. We present a series of 4 cases with RF associated with systemic sclerosis, 3 of them with ischaemic ulcers, who were treated with hyperbaric oxygen (HBO).

Clinical observation

The 4 patients were women aged between 34 and 57 years, 2 of whom were diagnosed with limited systemic sclerosis and the other 2 with diffuse systemic sclerosis. The main clinical features are summarised in Table 1. The patients were selected after previously ruling out severe interstitial lung involvement, which could be a risk factor for pulmonary barotrauma. Of these, 3 had digital hand ulcers before starting HBO treatment (2, 3 and 6, respectively) and 3 of them were receiving treatment for RF with an endothelin inhibitor or a calcium antagonist. The hyperbaric chamber treatment in all 4 cases consisted of a total of 30 sessions performed 4 days a week. In each session the patients stayed for one hour with 100% O2 at a pressure of 2.4 atmospheres absolute. Ulcer improvement was assessed according to the degree of epithelialisation (less than 50%, greater than 50% or complete epithelialisation). Additionally, the severity of RF was measured using the Spanish version of the Raynaud’s Condition Score (RCS), a self-administered questionnaire that patients completed daily for 14 days. The RCS captures the frequency, duration, severity and impact of RF episodes2.

Table 1.

Clinical characteristics of the four cases.

Patient  Age  Sex  Diagnosis  Time of evolution (years)  Systemic involvement  Antibody profile  Previous RP ttm  Current RP ttm  DU prior to HBOT  RP episodes/day prior to HBOTa  Episodios RP/día tras HBOTa  Dolor antes de HBOTb  Dolor tras HBOTb  Entumeci-miento antes de HBOTb  Entume-cimiento tras HBOTb 
Case 1  41  Female  Limited SSc  No  ACA  PG  CA  14  57,5  25  50,36  21 
Case 2  34  Female  Diffuse SSc  26  ILD, PH, esophageal, intestinal  Anti-Scl70  PG, CA  No  14  100  76  100  75 
Case 3  47  Female  Limited SSc  12  Esophageal  ACA  CA.  ERA  2,7  0,2  46,3  10,14  52  11,7 
Case 4  57  Female  Diffuse SSc  21  ILD, esophageal, intestinal  Anti-Scl70  PG  ERA, CA  3,5  2,5  33,9  46  26,7  17,6 

ACA: anticentromere; CA: calcium antagonist; DU: digital ulcer; ERA: endothelin receptor antagonist; HBOT: hyperbaric oxygen therapy; ILD: interstitial lung disease; PG: prostaglandins; PH: pulmonary hypertension; RP: Raynaud’s phenomenon; SSc: systemic sclerosis; Ttm: treatment.

a

Arithmetic mean of the number of episodes per day of Raynaud’s phenomena occurring in the previous 14 days, according to the Raynaud Condition Score.

b

Measured using a visual analogue scale from 0 to 100. Arithmetic mean of the score obtained in the previous 14 days according to the Raynaud Condition Score.

Three of the patients had complete epithelialisation of their digital ulcers. According to the results obtained in the RCS, all 4 patients experienced a decrease in the frequency of RF episodes and 3 of them also experienced less pain and less numbness during the episodes (Table 1). As a side effect, 2 patients experienced mild middle ear barotrauma, which required discontinuation of HBO therapy for one week, although they subsequently resumed therapy without further incident.

Discussion

The treatments used in secondary RF are mainly vasodilators, including calcium antagonists, phosphodiesterase E5 inhibitors, endothelin-1 inhibitors and prostaglandins3,4. Hyperbaric oxygen therapy consists of the administration of 100% oxygen in a closed chamber at a pressure of 2–3 atmospheres absolute (the hyperbaric chamber). This therapy has been used for the treatment of ulcers of different aetiologies due to its healing, angiogenic, anti-inflammatory and antimicrobial effect5. However, there are no clinical trials that support its usefulness in the treatment of digital ulcers associated with systemic sclerosis; only case reports have been found in the literature6–8. In this series, as a novelty, the impact of HBO on RF was also evaluated, and improvement was observed in 3 of the 4 patients. HBO therapy is considered a safe treatment, with middle ear barotrauma as the most frequent adverse event. Other adverse events, such as neurological oxygen toxicity or pulmonary barotrauma, are very rare9 if patients are appropriately selected.

Conclusions

HBO treatment could be a therapeutic alternative in patients with secondary RF who are intolerant or refractory to conventional treatments.

Conflict of interests

None to declare.

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Please cite this article as: Ahijón-Lana M, Baragaño-Ordóñez E, Veiga-Cabello R, de la Cruz-Tapidor C, Carreira PE. Tratamiento con oxígeno hiperbárico en el fenómeno de Raynaud y las úlceras digitales asociadas a esclerosis sistémicas. Reumatol Clin. 2022;18:246–248.

Copyright © 2021. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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