Scleroderma Digital Ulcers Complicated by Infection with Fecal Pathogens.

Background/Purpose: Digital ulcers represent one of the most frequent complications in the course of systemic sclerosis (SSc); these lesions are very painful, scarcely responsive to treatment, and usually responsible for marked limitations on daily activities. Moreover, infectious complications may severely compromise the outcome of skin lesions in a significant percentage of patients. Therefore, the presence of pain and bandages, frequently used to promote the efficacy of contact medications, may limit the personal hygiene with an increased risk of local infection and difficult ulcer healing. A number of pathogens of different origin may be involved, including bacteria from patients' endogenous flora. We evaluated the possible involvement of faecal pathogens in SSc digital ulcers.Methods: Among a series of 82 SSc patients with digital ulcers, we retrospectively analyzed 42 subjects with clinical signs of local bacterial infection. All digital ulcers with typical signs of infection (increase of yellow or green exudates, pain, perilesional erythema and swelling, bad odour) have been investigated by swabs.Results: The table summarizes the main clinico-serological and microbiological features of the 42 SSc patients with digital ulcer infection. Bacterial infection was confirmed in all 42 patients investigated; in particular, Staphylococcus aureus was the most frequently found (50%). Interestingly, 11/42 (26%) patients showed digital ulcers infected by intestinal bacteria; namely, 7 subjects resulted positive for Escherichia coli and 4 for Enterococcus faecalis. A significantly higher percentage of diffuse cutaneous SSc was recorded in the subgroup of 11 patients with digital ulcers infected by faecal pathogens compared to the remaining 31 infected by other bacteria (6/11 vs. 5/31, respectively; Fisher's p=0.011). Conclusion: A number of effective measures, involving health care personnel and hospital environment, are essential in the management of digital ulcers and prevention of infectious complications. The prevalence of faecal pathogens in a quarter of cases has never been reported previously; it suggests an important role of patient's self-care limitations, generally more frequent in patients with diffuse cutaneous SSc, mainly during intercurrent home medications. Consequently, methodical patients' education on hand hygiene is mandatory to avoid such deleterious complications.