Digital Ulcers Reduce Quality of Life, Increase Clinical and Economic Burden in Systemic Sclerosis

Systemic sclerosis, digital ulcers
Systemic sclerosis, digital ulcers
Researchers evaluated the frequency and clinical characteristics of systemic sclerosis-related digital ulcers, and associated direct healthcare costs, quality of life, and survival.

Systemic sclerosis (SSc)-related digital ulcers reduce health-related quality of life (HRQoL) and increase healthcare resource utilization and associated costs, according to study results published in Arthritis Research & Therapy.

This multicenter cohort study focused on data of consecutive patients with SSc who were prospectively enrolled in the Australian Scleroderma Cohort Study. A digital ulcer was defined as a skin area with visually discernible depth and loss of epithelial coverage continuity, and digital ulcer severity was based on the highest physician-reported number of new digital ulcers (mild=1-5, moderate=6-10, severe >10). Data linkage were used to capture healthcare use; SSc clinical data that had been prospectively captured in a clinical database were linked to health services databases to capture ambulatory care utilization, emergency department presentations, hospital admissions, and cost for the period from 2008 to 2015.

Of 1085 patients with SSc, 527 (48.6%) had at least 1 digital ulcer over a mean follow-up of 5.2±2.5 years. Compared with patients without a history of digital ulcers, patients with a history of digital ulcers were younger at SSc onset (43.6±13.9 vs 48.8±14.0 years; P <.001) and were more likely to have longer disease duration (12.2±10.5 vs 10.1±9.9 years; P =.001); these patients were more likely to have a diffuse disease subtype (34.9% vs 18.2%; P <.001) and be men (18.0% vs 11.5%, P =.002). Patients with a history of digital ulcers were also more likely to test positive for anti-RNA polymerase III or antitopoisomerase-1 antibody (16.9% vs 11.8%; P =.05 and 18.9% vs 9.3%; P <.001, respectively). Patients with digital ulcers had reduced HRQoL as measured by the 36-Item Short Form Health Survey (36.1±10.4 vs 39.2±11.2, P <.001); however, there was no significant effect on survival found in this study.

Patients with a history of SSc-related digital ulcers vs patients without a history of SSc-related digital ulcers had significantly higher total healthcare costs (hospital, emergency department, and ambulatory care) between 2008 and 2015. Among patients with a history of SSc-related digital ulcers, the total average healthcare cost per patient was AUD $46,364 (interquartile range [IQR], 24,561-92,582) compared with AUD $33,890 (IQR, 15,987-66,905; P <.001) among patients without a history of digital ulcers; median annual cost per patient was AUD $7854 (IQR, 5596-11,404) vs AUD $7060 (IQR, 4968-9893; P =.001), respectively. Costs did not significantly differ with digital ulcer severity.

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“[Digital ulcers] are a serious complication of SSc and place a large burden on the healthcare system and the patient through reduced HRQoL, incremental healthcare resource utilization and associated cost without [affecting] survival. To reduce the clinical burden of [digital ulcers], additional research is needed to determine effective interventions and management plans such as the development of a [digital ulcer] specific multidisciplinary clinic,” the researchers concluded.

Disclosure: This clinical trial was supported by Actelion Australia, Bayer, CSL Biotherapies, GlaxoSmithKline Australia, and Pfizer. Please see the original reference for a full list of authors’ disclosures.


Morrisroe K, Stevens W, Sahhar J, et al. Digital ulcers in systemic sclerosis: their epidemiology, clinical characteristics, and associated clinical and economic burden. Arthritis Res Ther. 2019;21(1):299.