{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T00:15:01Z","timestamp":1785888901084,"version":"3.56.0"},"reference-count":46,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2025,5,15]],"date-time":"2025-05-15T00:00:00Z","timestamp":1747267200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2025,5,15]],"date-time":"2025-05-15T00:00:00Z","timestamp":1747267200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"DOI":"10.13039\/501100023833","name":"world scleroderma foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100023833","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Journal of Scleroderma and Related Disorders"],"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction:<\/jats:title>\n                    <jats:p>Digital ulcers (DUs) stand out as one of the most prevalent and clinically meaningful manifestations of systemic sclerosis (SSc) and are associated with significant morbidity. While systemic (pharmacological) therapy is currently established as the \u2018standard of care\u2019, effective local ulcer management remains crucial for all cases of DUs. This is particularly true for patients who cannot tolerate systemic treatments or in the case of refractory SSc-DUs. On this background, there is a pressing demand for the formulation of evidence-based guidelines to assist clinicians and patients in navigating the local treatment options for DUs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>A steering committee of international experts was established by the World Scleorderma Foundation (WSF) Digital Ulcer (DU) ad hoc committee. Two systematic literature reviews on local non-surgical and surgical treatments for the management of SSc-DUs were performed to inform the development of local treatment recommendations for SSc-DUs. Consensus methodology was used to develop the final treatment recommendations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>Six overarching treatment principles and eight local treatment recommendations (five non-surgical and three surgical) were agreed upon for the management of SSc-DU. Among topical non-surgical options, botulin toxin can be conditionally recommended for refractory and\/or severe DUs. Among surgical treatments, autologous adipose tissue grafting might be recommended for DU healing when combined with background systemic treatments.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion:<\/jats:title>\n                    <jats:p>These recommendations are specifically tailored to guide treatment decisions concerning both local and non-pharmacological approaches to managing SSc-related DUs. Our work has highlighted a notable quality gap in comparison to systemic treatments, underscoring the scarcity of high-quality studies concerning this topic.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/23971983251339821","type":"journal-article","created":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T00:45:45Z","timestamp":1747356345000},"page":"276-284","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":5,"title":["Recommendations for the local management of digital ulcers in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) \u2018Ad hoc committee\u2019"],"prefix":"10.1136","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6806-3794","authenticated-orcid":false,"given":"Corrado","family":"Campochiaro","sequence":"first","affiliation":[{"name":"Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2919-1966","authenticated-orcid":false,"given":"Yossra A","family":"Suliman","sequence":"additional","affiliation":[{"name":"Assiut University Hospital, Assiut, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0041-3695","authenticated-orcid":false,"given":"Dilia","family":"Giuggioli","sequence":"additional","affiliation":[{"name":"Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pia","family":"Moinzadeh","sequence":"additional","affiliation":[{"name":"University Hospital of Cologne, Cologne, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessia","family":"Alunno","sequence":"additional","affiliation":[{"name":"Department of Life, Health &amp; Environmental Sciences, University of L\u2019Aquila, L\u2019Aquila, Italy"},{"name":"Internal Medicine and Nephrology Unit, Department of Medicine, ASL Avezzano-Sulmona-L\u2019Aquila, San Salvatore Hospital, L\u2019Aquila, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan W","family":"Schoones","sequence":"additional","affiliation":[{"name":"Directorate of Research Policy (formerly Walaeus Library), Leiden University Medical Center, Leiden, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Murray","family":"Baron","sequence":"additional","affiliation":[{"name":"Jewish General Hospital, McGill University, Montreal, QC, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorinda","family":"Chung","sequence":"additional","affiliation":[{"name":"School of Medicine, Stanford University, Palo Alto VA Health Care System, Palo Alto, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Ross","sequence":"additional","affiliation":[{"name":"The University of Melbourne, Melbourne, VIC, Australia"},{"name":"St Vincent\u2019s Hospital, Melbourne, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8535-4312","authenticated-orcid":false,"given":"Nancy","family":"Maltez","sequence":"additional","affiliation":[{"name":"The University of Ottawa, Ottawa, ON, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Begonya","family":"Alcacer-Pitarch","sequence":"additional","affiliation":[{"name":"Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3278-8296","authenticated-orcid":false,"given":"Khadija","family":"El-Aoufy","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yannick","family":"Allanore","sequence":"additional","affiliation":[{"name":"Paris Descartes University, Paris, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8528-2283","authenticated-orcid":false,"given":"Francesco","family":"Del Galdo","sequence":"additional","affiliation":[{"name":"Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3975-8938","authenticated-orcid":false,"given":"Christopher P","family":"Denton","sequence":"additional","affiliation":[{"name":"University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oliver","family":"Distler","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5472-3840","authenticated-orcid":false,"given":"Tracy","family":"Frech","sequence":"additional","affiliation":[{"name":"Veterans Affairs Medical Center, University of Utah, Salt Lake City, UT, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel E","family":"Furst","sequence":"additional","affiliation":[{"name":"University of California, Los Angeles, Los Angeles, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6822-3401","authenticated-orcid":false,"given":"Dinesh","family":"Khanna","sequence":"additional","affiliation":[{"name":"University of Michigan, Ann Arbor, MI, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Krieg","sequence":"additional","affiliation":[{"name":"Department of Dermatology and Venereology, University Hospital of Cologne, Cologne, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8352-6136","authenticated-orcid":false,"given":"Masataka","family":"Kuwana","sequence":"additional","affiliation":[{"name":"Nippon Medical School, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Matucci-Cerinic","sequence":"additional","affiliation":[{"name":"Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milano, Italy"},{"name":"Vita Salute San Raffaele University, Milano, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1479-5302","authenticated-orcid":false,"given":"Janet","family":"Pope","sequence":"additional","affiliation":[{"name":"Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Hughes","sequence":"additional","affiliation":[{"name":"Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK"},{"name":"Division of Musculoskeletal and Dermatological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,5,15]]},"reference":[{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.5301\/jsrd.5000249"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2015-208121"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/J.LPM.2021.104064"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00296-019-04436-z"},{"key":"e_1_3_2_6_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41584-020-0386-4"},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/keu296"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1001\/jamadermatol.2021.1463"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2665-9913(19)30164-X"},{"key":"e_1_3_2_10_2","doi-asserted-by":"publisher","DOI":"10.1046\/J.1524-475X.11.S2.1.X"},{"key":"e_1_3_2_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.semarthrit.2023.152267"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.semarthrit.2023.152266"},{"key":"e_1_3_2_13_2","unstructured":"Cochrane Bias. RoB 2: a revised Cochrane risk-of-bias tool for randomized trials. https:\/\/methods.cochrane.org\/bias\/resources\/rob-2-revised-cochrane-risk-bias-tool-randomized-trials (accessed February 25 2023)"},{"key":"e_1_3_2_14_2","unstructured":"Cochrane Bias. ROBINS-I. https:\/\/methods.cochrane.org\/bias\/risk-bias-non-randomized-studies-interventions (accessed February 25 2023)"},{"key":"e_1_3_2_15_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-021-05900-7"},{"key":"e_1_3_2_16_2","doi-asserted-by":"publisher","DOI":"10.1111\/1346-8138.13030"},{"key":"e_1_3_2_17_2","doi-asserted-by":"publisher","DOI":"10.1177\/1753193413516242"},{"key":"e_1_3_2_18_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00296-020-04606-4"},{"issue":"3","key":"e_1_3_2_19_2","first-page":"154","article-title":"Evaluation of botulinum toxin A injections for the treatment of refractory chronic digital ulcers in patients with systemic sclerosis","author":"Lautenbach G","year":"2020","unstructured":"Lautenbach G, Dobrota R, Mihai C, et al. Evaluation of botulinum toxin A injections for the treatment of refractory chronic digital ulcers in patients with systemic sclerosis. Clin Exp Rheumatol 2020; 38 suppl 125(3): 154\u2013160.","journal-title":"Clin Exp Rheumatol"},{"key":"e_1_3_2_20_2","doi-asserted-by":"publisher","DOI":"10.1002\/art.42342"},{"issue":"3","key":"e_1_3_2_21_2","first-page":"51","article-title":"Vitamin E gel reduces time of healing of digital ulcers in systemic sclerosis","volume":"27","author":"Fiori G","year":"2009","unstructured":"Fiori G, Galluccio F, Braschi F, et al. Vitamin E gel reduces time of healing of digital ulcers in systemic sclerosis. Clin Exp Rheumatol 2009; 27(3) suppl 54: 51\u201354.","journal-title":"Clin Exp Rheumatol"},{"key":"e_1_3_2_22_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/key410"},{"key":"e_1_3_2_23_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0190-9622(89)70161-4"},{"key":"e_1_3_2_24_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-010-1653-6"},{"key":"e_1_3_2_25_2","doi-asserted-by":"publisher","DOI":"10.1620\/tjem.238.39"},{"key":"e_1_3_2_26_2","doi-asserted-by":"publisher","DOI":"10.1007\/s40744-022-00438-9"},{"key":"e_1_3_2_27_2","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-020-04966-z"},{"key":"e_1_3_2_28_2","doi-asserted-by":"publisher","DOI":"10.1055\/s-0034-1376970"},{"key":"e_1_3_2_29_2","doi-asserted-by":"publisher","DOI":"10.3727\/096368914X685636"},{"key":"e_1_3_2_30_2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2014-205681"},{"key":"e_1_3_2_31_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.retram.2016.10.006"},{"key":"e_1_3_2_32_2","doi-asserted-by":"publisher","DOI":"10.1186\/s13075-018-1792-8"},{"key":"e_1_3_2_33_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00266-020-01848-2"},{"key":"e_1_3_2_34_2","doi-asserted-by":"publisher","DOI":"10.3390\/jcm9093023"},{"key":"e_1_3_2_35_2","doi-asserted-by":"publisher","DOI":"10.1097\/01.prs.0000178795.21651.cc"},{"key":"e_1_3_2_36_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhsa.2009.05.003"},{"key":"e_1_3_2_37_2","doi-asserted-by":"publisher","DOI":"10.1002\/micr.22379"},{"key":"e_1_3_2_38_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0266-7681(97)80402-0"},{"key":"e_1_3_2_39_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhsa.2007.08.003"},{"key":"e_1_3_2_40_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/keab510"},{"key":"e_1_3_2_41_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/kead289"},{"key":"e_1_3_2_42_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.semarthrit.2023.152266"},{"key":"e_1_3_2_43_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.semarthrit.2023.152267"},{"key":"e_1_3_2_44_2","doi-asserted-by":"publisher","DOI":"10.1136\/ard.2008.096677"},{"key":"e_1_3_2_45_2","doi-asserted-by":"publisher","DOI":"10.1136\/annrheumdis-2023-eular.1383"},{"key":"e_1_3_2_46_2","doi-asserted-by":"publisher","DOI":"10.2147\/JMDH.S295478"},{"key":"e_1_3_2_47_2","doi-asserted-by":"publisher","DOI":"10.1093\/rheumatology\/keae130"}],"container-title":["Journal of Scleroderma and Related Disorders"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/23971983251339821","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/23971983251339821","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/23971983251339821","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T11:53:04Z","timestamp":1777981984000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/23971983251339821"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,15]]},"references-count":46,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2025,10]]}},"alternative-id":["10.1177\/23971983251339821"],"URL":"https:\/\/doi.org\/10.1177\/23971983251339821","relation":{},"ISSN":["2397-1983","2397-1991"],"issn-type":[{"value":"2397-1983","type":"print"},{"value":"2397-1991","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,15]]}}}