Background/Purpose: Digital ulcers (DU) and Raynaud’s phenomenon (RP) are a frequent complication in patients with Systemic Sclerosis (SSc). The present study aimed to evaluate the frequency and severity of RP and DU in patients with SSc in four distinct geographic regions of Brazil in order to evaluate the influence of geographic variation on the risk of DU development. 

Methods: One hundred and forty-one patients with SSc according to the ACR/EULAR classification criteria of 2013, from centers located in four regions of Brazil (Northeast, Midwest, Southeast and South), were evaluated from January to March 2012. Demographic, clinical, and nailfold capillaroscopy data were collected. The daily mean temperature and the mean temperature in the week before evaluation were also recorded. In order to evaluate a possible association between DUs and climate, the group of patients from the South region (Subtropical climate zone, with lower temperatures), was compared to those from the other regions (Tropical climate zone). Comparisons between groups were made using t-test or chi-square test. Simple and multiple logistic regression models were applied to determine the association between DUs and clinical and demographic variables.  

Results: A total of 43 active DUs were observed in 23 (16%) of the 141 patients included. Eighty-six percent were women, with a mean age of 47.8 years, a mean duration of RP of 10.1 years and a mean duration of disease of 5.8 years. Forty-three percent had limited cutaneous SSc, 61.7% had digital pitting scars and 12.1% had a previous history of gangrene or amputation. Twenty-six (18.4%) patients were from the Subtropical climate zone and 115 (81.6%) from the Tropical climate zone, with no difference on age, gender, RP and disease duration between groups. By simple logistic regression model, the presence of DU was associated with a higher modified Rodnan skin score (P=0.023), presence of necrosis or amputation (P=0.008), presence of flexion contracture of the fingers (P=0.002), active smoking (P=0.038), higher avascular score on nailfold capillaroscopy (P=0.019), higher severity of RP in the last week (P=0.007), a higher sHAQ score (P=0.001), and with the Subtropical climate zone patient group (P=0.011). The presence of DU was not significantly associated with the mean daily temperature or the temperature in the week before the evaluation. Using multiple logistic regression model including the significant associations observed in univariate analysis, presence of DU was significantly associated with patients living in the Subtropical climate zone (odds ratio [OR]=3.5, 95% confidence interval [95%CI]=1.10-11.28, P=0.034), with a previous history of necrosis or amputation (OR=4.7, 95%CI=1.20-19.10, P=0.026) and with a higher sHAQ (OR=4.7, 95%CI=1.81-12.5, P=0.002).  

Conclusion: This was the first study to evaluate the influence of temperature and geographic variation on DU prevalence in SSc patients. In this multicenter study in a continental country with different climates, patients with SSc living in a colder region (Subtropical climate zone) have a 3.5 times higher risk of developing DU than those patients living in a warmer region (Tropical zone).

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/impact-of-geographic-variation-on-the-risk-of-digital-ulcers-development-in-systemic-sclerosis-a-brazilian-multicenter-registry/