Presentation by Nancy Rivera, RN at the Scleroderma Foundation Greater Chicago Chapter's spring 2018 Patient Education Conference.

1. Scleroderma andYour
Skin
Nancy S. Rivera RN, MS,
ANP-C, CWON
Nurse Practitioner
Certified Wound/Ostomy Nurse

2. Objectives
• Upon completion of this presentation the
participant will be able to:
• Describe associated skin changes
• Discuss prevention of skin complications
• Discuss self management and wound healing
strategies
• Verbalize awareness of medical management
strategies.

3. Disclaimer
• No products are officially endorsed. Talk
to your health care provider before
initiating any new products.

4. Review of Scleroderma
• Chronic Autoimmune Tissue Disorder
• Women 4x more likely to develop
• More common in African Americans and some Native Americans
• Overproduction of collagen –pathology complicated
• Too much collagen causes tissue to become thick and lose flexibility.
• The immune system responds with inflammation. Then the body makes
more collagen.
• Localized
• Systemic
• Limited: slower progression
(anticentromere antibodies)
• Diffuse: more rapid onset and
progression (anti-scl70 antibodies)

5. So What Does That Mean?
• Skin thickening, tightening
• Loss of subcutaneous fat
• Epidermal Atrophy (loss of skin
flexibility and stretch, loss of sweat
glands and hair)
• Swelling, stiffness, and pain in the
fingers, toes, hands, feet or face.
• Tingling, numbness, Itching, or
puffiness in fingers or toes.
• Skin discoloration or small white
bumps under the surface of the skin
(calcinosis)
• Red spots from dilated blood vessels
on the fingers, palms, face, lips or
tongue (telangectasias)
• Ulcers or sores on fingertips,
knuckles or elbows that are difficult
to heal

6. Also: Blood vessel damage and
narrowing, calcium deposits

9. Raynaud’s Syndrome
• Spasms of blood vessels in
response to cold and/or stress
• White, bluish, or reddish tint in
the hands or feet.
• Painful!
• Frequently the presenting
symptom, most people
develop during course of the
disease.
• Includes nail-fold capillary
changes

11. Digital Ulcers
• Occur in more than 30% of patients
• Recurrence rate 50%
• Occur early in disease course
• 43% within first year (Hachulla J Rheum 2007)
• 20% have 3-6 ulcers per episode
• Commonly at fingertips, finger joints and toes,
where skin is stretched. Joints are where calcium
deposits and deformities also occur.
• Combination of dry, tough skin, chronic inflammation,
and vascular spasms/narrowing (decreased
oxygenation) creates an inability of the body to
undergo normal process of wound healing.

12. High Quality of Life Burden
• Interferes with activities of daily living
• Restricts an individual’s capabilities
• Impairs hand function
• Impacts work opportunities and
family commitments
• Increased disability and reduced
quality of life
• Very painful with prolonged healing
time.
• Risk of infection
• Risk of necrosis and amputation

13. Avoid Temperature
extremes
• Causes blood vessel spasms
• Avoid air conditioning
• Refrigerators/freezers: Use
rubber gloves with liners
• Shopping/grocery stores-be
aware of cold exposure
• Decrease caffeine consumption
• Cold beverages – use a
Koozie/hugger

14. Keep warm (entire body and
extremities)
• Gloves/mittens, hats,
earmuffs, heavy socks
• Layered clothing
• For outdoor exercise:
synthetics, smart wool
• Warms bath/shower
• Hand warmers, heating pads,
heated mattress pads, hot water
bottles, space heaters: but be
careful esp if have neuropathy.
• Get kind that automatically turn
off!

15. This goes without saying….

16. Meticulous Hand Care:
Keeping hands/feet clean
• No hot baths, lukewarm only
• Don’t scrub / pat dry/ make sure between toes / skin pat dry
• Wash with non-foaming soaps
• Epsom salt soaks
• African Black soap
• Organic / natural soaps without additives
• No antibacterial soaps
• READ the LABELS! Avoid products with:
• Retinol, Retinoid, Retin A
• Vitamin A
• Vitamin C
• Alpha hydroxyl acid
• These products encourage production of collagen and stop collagen
break down- they are great for anti-aging, BUT worsen scleroderma
skin changes

17. Moisturize and Protect
• Use an Emollient
• An emollient is a
1. humectant (enhances body’s ability to hold water)
2. lubricant (reduces friction) and
3. an occluder (slows down water loss)
• Apply after bathing or washing hands
• Use at least 3x day
• At night, wear cotton gloves
• No moisturizing between toes
• Avoid trauma
• Common emollients:
• Shea butter, Cocoa butter, Mineral oil, Lanolin, Petrolatum,
Paraffin, Beeswax, Squalene, Coconut, jojoba, sesame,
almond, and other plant oils, Olive oil (oleic acid),
Triethylhexanoin (glycerin)

18. Avoid Irritants
• Sodium Lauryl Sulfate: detergent and foaming agent
• Known skin irritant that can damage skin barrier function
• Fragrances

19. Other products
• Urea products
• Soften skin
• Promote pH balance
to protect acid mantle
• Mild local anesthetic
• Moisturizer for extra
dry skin
• Sunscreen and
clothing protection
always.

20. Examples

21. Check
• Examine your hands
and feet for cracks
and ulcerations
• Initiate treatment
promptly
• If you can’t see well,
have someone help.
• Watch for s/s infection:
• Increased swelling
• Increased redness
• Pus
• Increased pain
• May be difficulty to
discern infection from
inflammation.
• See your doctor.

22. What to do if you have an ulcer:
• Wash it. OK to soak
in Epsom salt for few
minutes. Don’t use
hydrogen peroxide
and if you do, make
sure you rinse well
after.
• Pat dry.
• Don’t pick it.
• Apply:
• Skin sealant and
bandage OR
• Antiseptic ointment
and bandage OR
• Antiseptic bandage
• Change every other
day OR if soiled, wet
or damaged.

23. Skin Sealants

24. Antiseptic ointment

25. Bandages

26. After care
• Avoid getting wet.
• Avoid contamination
(Gluggioli et al 2011)
• Be patient
• Pain management
• If not improving within
2 weeks OR if you
have concerns: See
your friendly wound
care specialist
• More toys
• Assess expertly
• Debride necrotic tissue
• Extract calcinosis
deposits

27. Other Possibilities
• Medications that improve blood flow
• Medications that reduce risk of clots
• Medications that reduce inflammation
• Medications that block immune system
• Vitamin E gel / oral supplementation
• Botulinum toxin
• Hyperbaric oxygen therapy
• Stress management
• Biofeedback
• Stem cells
• Surgical intervention
• Research studies
• Cannabis for pain?
•

28. A word about nutrition….
• The issues:
• Esophageal dysfunction
• GERD
• Jaw muscle pain while eating
• Mouth opening may be difficult making eating and chewing a
challenge
• Dry mouth along with gum recession adds to oral /teeth problems
• Fatigue
• Difficulty preparing meals
• Difficulty shopping
• Chronic pain
• Loss of appetite
• Bowel irregularity

29. Nutrition pointers
• Small bites of food, have liquid to
wash it down
• Frequent natural meals, nutrient rich
• Calories first! (myfitnesspal.com)
• Adequate protein (1 gm/kg)
• Healthy fats
• Antioxidant rich/anti-inflammatory
herbs and spices: basil, rosemary,
oregano, cinnamon, ginger, paprika,
cayenne, tumeric
• Lots of fiber: Today Temptations
whole wheat/ whole grain bread
• Avoid milk (lactose)
• Avoid fake sugars
• Supplements
• Multi vitamin
• Omega 3 supplements
• ? Vit D
• B12
• Probiotics: Align, Culturelle, live
culture yogurt, fermented
foods.
• Weigh self once /week and log.
See your HCP for unexplained
weight loss.
• Stool softeners / smooth move
Tea / Magnesium oxide
supplements
• Watch for signs of bleeding –
bright red blood, black stools

30. Telangiectasia
• Widened tiny veins which cause threadlike red lines or
dot to dot patterns
• Spider veins
• Lips, nose, eyes, fingers, cheeks, hands, trunk
• Cosmetic
• Laser therapy
• Sclerotherapy
• Makeup

31. Conclusion/Questions?

32. Thank you!