Special Health Reports

Healthy Hands: Strategies for Strong, pain free hands

Arthritis of the hand

Joint inflammation, or arthritis, is the leading cause of disability among Americans, causing stiffness, swelling, pain, and loss of motion and function. There are more than 100 kinds of arthritis, including osteoarthritis and rheumatoid arthritis. Arthritis can affect any joint in the body, but it is most visible when it affects the hands.

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Osteoarthritis

The most common of all joint diseases, osteoarthritis affects cartilage, the resilient tissue that cushions the ends of your bones. Normally, cartilage provides a smooth, gliding surface so the joints can move easily. In osteoarthritis, the cartilage thins and loses its elasticity. As the cartilage breaks down, the underlying bone may form a bony growth called a spur, or osteophyte. Fluid-filled cysts may form in the bone near the joint. The synovial membrane lining the joints becomes inflamed, triggering the release of proteins that may damage the cartilage further.

Approximately 27 million Americans have osteoarthritis. In addition to the hands, osteoarthritis typically strikes the knees, hips, feet, and spine. The incidence rises with age, with most cases occurring in people older than 50. Heredity seems to play a role, particularly for osteoarthritis in the hands. Muscle weakness and a history of joint injuries caused by sports or accidents may also make a person more prone to a type of osteoarthritis known as traumatic arthritis. Ordinary, repetitive activities such as typing or playing a musical instrument may worsen arthritis symptoms, but they do not cause osteoarthritis of the hands.

  • Pain in the morning, which gradually recedes but returns at the end of the day
  • Pain that is alleviated by resting the affected joint
  • Stiffness in the affected joint

Diagnosing osteoarthritis

To diagnose any type of arthritis, your doctor will order blood tests to rule out other possible causes of your symptoms. He or she will ask specific questions about your symptoms, such as when they first started and how they affect your life. Details of your personal and family medical history may also be relevant.

Your doctor will take x-rays of the affected joints, which can reveal evidence of bone spurs and signs of cartilage breakdown within the joint. Most people older than 60 have signs of arthritis on an x-ray, but only about one-third have symptoms. There is often a big difference between the severity of osteoarthritis seen on an x-ray and how much pain and disability a person feels.

Certain joints of the hands are especially susceptible to osteoarthritis:

  • The distal interphalangeal (DIP) joint—the last joint before the nail on each finger (see Figure 1)—is the most common site for osteoarthritis of the hands. These joints sometimes develop fibrous, bony nodules called Heberden's nodes.
  • The basal or first carpometacarpal (CMC) joint—located at the base of the thumb, where the thumb and wrist come together—is the second most common joint to develop osteoarthritis of the hands. It is formed by wrist bones and the first of the three bones in the thumb (the metacarpal). The shape of these bones allows your thumb to move up and down, bend across the palm, and pinch with each of the fingers. Past injuries to this joint, such as a fracture or sprain, may increase the odds of getting arthritis in this joint.
  • The proximal interphalangeal (PIP) joint—the middle joint of each finger—can also develop osteoarthritis, causing the fingers to stiffen and swell. Fibrous and bony nodules, known as Bouchard's nodes, may develop in these joints.
  • The metacarpophalangeal (MCP) joints—where the fingers join the rest of the hand­—are sometimes affected by osteoarthritis as well. These knuckle joints act as hinges between the long bones in the hand and the smaller bones in the fingers. Swelling of these joints, which may give the hands a spindle-like appearance, is common in people with rheumatoid arthritis. Injuries or other diseases, such as gout or psoriasis, can also cause problems.

Cracking your knuckles may provoke an annoyed grimace from those around you, but it probably won't raise your risk for arthritis. That's the conclusion of several studies that compared rates of hand arthritis among habitual knuckle-crackers and people who didn't crack their knuckles.

The "pop" of a cracked knuckle is caused by bubbles bursting in the synovial fluid. The bubbles pop when you pull the bones apart, either by stretching the fingers or bending them backward, creating negative pressure. One study's authors compared the sudden, vibratory energy produced during knuckle cracking to "the forces responsible for the destruction of hydraulic blades and ship propellers."

Even if knuckle cracking doesn't cause arthritis, there's still good reason to let go of the habit. Chronic knuckle-crackers were more likely to have swollen hands and reduced grip strength. And there are at least two published reports of injuries suffered while people were trying to crack their knuckles.

Mucous cysts are clear or flesh-colored nodules that form on the fingers under the skin at the DIP joints. They occur most commonly in middle-aged or older women with osteoarthritis. These cysts often don't cause any symptoms, but sometimes are tender and painful and may limit your finger mobility, leading to stiffness and deformity. They rarely go away on their own and may drain spontaneously and become infected, requiring prolonged antibiotic treatment. More stubborn cysts may require a hand surgeon, who will open the joint and remove the cyst as well as any associated bone growth or spur (osteophyte).

Treating arthritic hands

Managing pain and improving function are the key goals in treating osteoarthritis. The best approach is usually a combination of different therapies, which can include splinting, joint protection, heat or cold therapy, exercise, medication, alternative remedies, and, in some cases, surgery.

Splinting. The first line of action for treating arthritis hand pain is splinting to immobilize the joint. This allows the joint to rest so the initial pain can subside. Splints can be used to support the painful joint during the day or at night.

Joint protection. If you have osteoarthritis, it's important to learn to recognize your body's signals to stop or slow down. A hand therapist can help you with this. To prevent pain caused by overexertion, take time to rest, and pace yourself by taking frequent breaks. Using specialized products and assistive devices can also make a big difference (see "Getting a grip: Handy gadgets and advice"). Modifying tasks to make them less stressful allows you to continue to do the things you need or want to do while alleviating the symptoms of arthritis.

Heat or cold therapy. You can often soothe painful joints without medications. A warm bath or shower can ease pain and stiffness. Other times, usually after exercise or exertion, cold therapy may work better. You can place a bag of ice or frozen vegetables wrapped in a towel on the joint or use a freezer gel pack, available at drugstores. Check with a doctor or therapist to find out whether heat or cold is the best treatment for you.

Exercise. Therapeutic exercise helps people with osteoarthritis in many ways: by improving mood, decreasing pain, and increasing flexibility and fitness over all. Therapeutic exercises, especially range-of-motion exercises for the thumb and wrist, help keep hand joints working as well as possible (see "Exercises for the hands"). Gentle, pain-free strengthening may be appropriate once the inflammation and pain have subsided. Consult a hand therapist for specific exercises for your hand problem, since doing the wrong type of exercise for your particular condition may make the problem worse.

Medication. Doctors prescribe a number of medications for arthritis, including topical and oral painkillers (see Table 1, and Table 2). One prescription gel, diclofenac (Voltaren), offers modest relief for hand arthritis. Other over-the-counter gels and creams haven't been studied as thoroughly, but some people find them helpful in treating mild to moderate pain. Topical medications can be a good choice for people with gastrointestinal conditions. For more severe pain, oral medications are typically more effective. Those that are in the class known as nonsteroidal anti-inflammatory drugs (NSAIDs), such as the over-the-counter pain relievers ibuprofen (Advil, Motrin) and naproxen (Aleve), also curb inflammation. For short-term relief, corticosteroids, known informally as steroids, can be injected directly into a joint to relieve pain. Be aware, however, that excessive injections actually increase the destruction of bone and cartilage

Topical pain relievers work best on joints close to the skin surface, such as those in the hands. One of these, diclofenac, is only available by prescription as either a gel or patch; both forms relieve mild to moderate joint pain and inflammation. The others, which are available over the counter, are moderately effective for mild pain. None, however, will alter the course of the arthritis. Do not use these on broken or irritated skin or in combination with a heating pad or bandage.

GENERIC NAME (BRAND NAME)

ACTIVE INGREDIENT

HOW IT WORKS

SIDE EFFECTS

COMMENTS

capsaicin (Capzasin, Zostrix, others)

Derived from cayenne peppers

Depletes substance P, which is believed to send pain messages to the brain

Temporary burning or stinging at the application site, which usually disappears within a few weeks of continuous use

Wash your hands thoroughly after use. Avoid contact with the eyes.

counterirritants (ArthriCare, Eucalyptamint, Icy Hot, Therapeutic Mineral Ice, others)

Include pungent oils derived from mint, wintergreen, eucalyptus, and other plants

Stimulate or irritate nerve endings to distract the brain's awareness of pain

Skin redness and irritation at application site

Many of these products have strong odors.

diclofenac (Voltaren Gel, Flector Patch)

A nonsteroidal anti-inflammatory drug (NSAID)

Inhibits hormone-like substances (prostaglandins) that contribute to pain and inflammation

Do not use with oral NSAIDs. Long-term users of either product should receive periodic blood tests to monitor liver function.

salicylates (Aspercreme, Bengay, Flexall, Mobisyl, Sportscreme, others)

A type of NSAID derived from willow tree bark

Same as for both diclofenac and counterirritants (see above)

Do not use if you are allergic to aspirin or are taking blood thinners.

All of these medications except acetaminophen are NSAIDs. Avoid NSAIDs if you have gastrointestinal problems, and take them with food, milk, or an antacid to minimize stomach problems.

acetaminophen (Tylenol, others)

Relieves pain

Nausea, vomiting, diarrhea, jaundice, rash, tiredness, weakness; less likely to cause gastric bleeding than other pain relievers

Drinking large amounts of alcohol during long-term therapy with acetaminophen may cause liver damage. Kidney damage also possible with long-term use.

aspirin (Bayer, Bufferin, others)

Reduces inflammation and relieves pain

Stomach pain, bleeding, ulcers

High doses may cause ringing in the ears. Before using, let your doctor know if you are on blood thinners or have liver or kidney problems.

ibuprofen* (Advil, Motrin, others)

Stronger and generally longer-lasting than aspirin.

naproxen* (Aleve)

Longer-lasting than ibuprofen.

* Ibuprofen and naproxen are available in higher doses by prescription only. Naproxen is also sold by prescription in combination with a medication to suppress stomach acid (either lansoprazole or esomeprazole), under the brand names Prevacid NapraPAC 500 and Vimovo.

Alternative or complementary therapies. These span a wide range of treatments, including yoga, acupuncture, and dietary supplements (see "Alternative and complementary treatments for arthritis," for details).

Surgery. This option usually is recommended only after other treatments have failed. Several surgical procedures are used for osteoarthritis, the most common being the removal of cysts and osteophytes at the DIP joint. People with severe osteoarthritis may be candidates for joint fusion or joint replacement (see "Advances in artificial joints for the hand").

Rheumatoid arthritis

Rheumatoid arthritis is much less common than osteoarthritis. Still, it affects about 1.5 million Americans, about 70% of them women. A chronic inflammatory condition, rheumatoid arthritis most commonly strikes the small joints of the wrist, hands, and feet. However, it can also strike the joints in the neck, shoulders, elbows, hips, knees, and ankles. Misshapen fingers that make many everyday tasks nearly impossible are one telltale sign of advanced disease. Rheumatoid arthritis usually affects both sides of the body in a symmetrical fashion. Affected joints often swell, feel warm and tender, and may be especially stiff and painful when you wake up or after you rest.

  • Swelling, warmth, and stiffness in the affected joints, especially in the morning or after rest
  • Usually affects joints on both sides of the body
  • In some cases, also fatigue, loss of appetite and energy, fever, or anemia

The disease is widely considered to be an autoimmune disorder, meaning the body's immune system goes awry and mistakenly attacks its own organs or tissues. There's some evidence that certain genes may make people more likely to have the disease, which can run in families.

In rheumatoid arthritis, the immune system attacks the synovium (joint lining), which then releases enzymes that destroy nearby cartilage. This causes redness, pain, and swelling. Eventually, the joints become enlarged, which hinders normal movement. Your fingers may swell and appear sausage-shaped, and you may develop a soft, lumpy mass over the back of your hand. You may hear a creaking sound (called crepitus) when you move your fingers.

Over time, the ligaments and tendons that hold bones in place stretch and weaken, causing your bones to become misaligned. The MCP joints are often affected. Your fingers may shift away from the thumb, a problem known as ulnar deviation or ulnar drift. The pain and deformity can be quite debilitating. You may find it hard to hold a cup, tool, or eating utensil. Other daily tasks such as combing your hair and buttoning your shirt can be challenging. (See "Getting a grip: Handy gadgets and advice," for tips on coping with these limitations.)

Inflammation from rheumatoid arthritis can cause the tendons to swell and rupture, resulting in permanent bending of the fingers. One condition of this type is called a boutonnière deformity, from the French word for buttonhole, so named because it involves a small tendon tear that resembles a buttonhole. Another is a swan-neck deformity, in which the middle joint of the finger (the PIP joint) hyperextends (see Figures 2 and 3).

When inflammation damages tendons and ligaments that normally keep a joint straight, the fingers can become deformed.

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Boutonnière deformity results from damage to tendons that straighten the middle joint of the finger.

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Swan-neck deformity occurs when inflammation stretches ligaments that keep fingers in proper alignment.

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These photos and x-rays come from two patients and show some of the many hand problems that can occur in rheumatoid arthritis. The pointers highlight just a few of them.

Diagnosing rheumatoid arthritis

In addition to a medical history and physical exam, doctors use both imaging and lab tests to diagnose rheumatoid arthritis. No single lab test can confirm whether a person has rheumatoid arthritis, but several blood tests can help clarify the diagnosis. For example, about 70% to 80% of people with rheumatoid arthritis have an antibody known as rheumatoid factor in their blood. Another blood test is for C-reactive protein (CRP), which is an indicator of inflammation. X-rays can reveal swelling of soft tissues, bone loss around the joints, and bone damage (called erosions) near the joints. More sophisticated imaging tests such as magnetic resonance imaging (MRI) can detect early inflammation, even before it's visible on an x-ray, and can pinpoint synovitis (inflammation of the lining of the joint).

Treating rheumatoid arthritis

As with osteoarthritis, doctors recommend painkillers (see Table 1 and Table 2), and, in some cases, corticosteroids to help manage pain and swelling. But decades of research show that early treatment with powerful drugs known as disease-modifying antirheumatic drugs (DMARDs) can lessen the chance of long-term disability from rheumatoid arthritis for some people. As a result, most people with rheumatoid arthritis take a DMARD, usually methotrexate. Another option is a group of drugs known as biological response modifiers (BRMs), which work by inhibiting specific components of the immune system (see Table 3, for more details).

These medications are prescribed for people with rheumatoid arthritis and related types of inflammatory arthritis.

GENERIC NAME (BRAND NAME)

SIDE EFFECTS/COMMENTS

Disease-modifying antirheumatic drugs (DMARDs)

These powerful drugs are prescribed early to relieve pain and swelling, limit joint damage, and alter the course of the disease.

hydroxychloroquine (Plaquenil)

leflunomide (Arava)

methotrexate (Folex, Rheumatrex, Trexall)

sulfasalazine (Azulfidine)

Can take weeks or months to work. Side effects vary with each medication and include increased risk for infection, hair loss, stomach upset, rash, and kidney or liver damage. Any of these drugs may interact with other medications. Methotrexate can suppress the immune system and may cause birth defects. Leflunomide may also cause birth defects. All DMARDs require close supervision and monitoring by a physician.

Kinase inhibitor

This one-of-a-kind drug affects the inflammatory mechanism inside cells and is used for moderate to severe rheumatoid arthritis in people who do not respond to methotrexate or another DMARD.

tofacitinib (Xeljanz)

Pill taken twice daily, reduces inflammation. Side effects may include diarrhea, headache, runny or stuffy nose, sore throat.

Biological response modifiers (BRMs)

These drugs, also known as biologics, are created from genetically engineered proteins derived from human genes. Given by injection or intravenous infusion, they inhibit specific components of the immune system, helping to suppress inflammation and slow the progression of rheumatoid arthritis.

Anti-TNF compounds:

• adalimumab (Humira)

• certolizumab (Cimzia)

• etanercept (Enbrel)

• golimumab (Simponi)

• infliximab (Remicade)

Side effects vary depending on the medication and include an increased risk for infections, from colds and sinus infections to more serious diseases such as tuberculosis.

Other biological response modifiers:

• abatacept (Orencia)

• anakinra (Kineret)

• rituximab (Rituxan)

• tocilizumab (Actemra)

Side effects vary but may include nausea, diarrhea, heartburn, muscle or back pain, tiredness, weakness, numbness in the hands or feet, stomach area pain. Tocilizumab may cause serious infections, diverticulitis, severe allergic reactions, and increases in blood lipids.

Because DMARDs have proven so successful in keeping rheumatoid arthritis at bay, hand surgeons have seen a decline in the number of people who need surgery. But for those whose symptoms become debilitating despite medical therapies, surgery is an option. Surgery for rheumatoid arthritis strives to reduce pain and improve function, and can also improve the appearance of your hands. Soft tissue removal (synovectomy, tenosynovectomy) involves removing diseased tissue from the tendons and joints. The surgeon may also reposition some tendons and release others to stop the fingers from drifting toward the little finger. Although synovectomy can decrease pain and swelling and slow joint destruction, the condition often recurs. Increasingly, surgeons are replacing wrist joints (and in some cases, MCP and PIP joints) destroyed by rheumatoid arthritis (see the special section, "Advances in artificial joints for the hand").

Treatment for rheumatoid arthritis of the hands is similar to treatment for osteoarthritis and includes splinting, joint protection, pacing, ergonomics, and gentle exercise. These therapies may be key to managing your symptoms and regaining your function. It's important to seek medical advice early because it may help you detect when the condition is getting worse and begin treatment to prevent deformities.

Other types of arthritis that affect the hands

Several other, less-common types of arthritis, including gout and pseudogout, can cause debilitating hand symptoms. In addition, conditions such as lupus, scleroderma, and psoriatic arthritis may cause arthritic symptoms that involve the hands.

Gout

Gout accounts for about 5% of all cases of arthritis. This condition is caused by deposits of tiny, needle-like crystals that form when the body either makes too much uric acid or excretes too little of it. Uric acid forms from the breakdown of purine, a substance found in protein-rich foods. The symptoms of gout resemble those of rheumatoid arthritis (joint pain, tenderness, warmth, and redness), but gout tends to affect only one joint at a time, and it may begin suddenly—often in the middle of the night. Pain may be quite severe and tends to resolve within a few days. Gout is most common in the big toe joint. However, it often affects other joints in the feet, ankles, and hands, as well as elsewhere in the body.

  • Jolts of pain in the affected joint
  • Possible inflammation of the joint
  • Increase in symptoms after eating certain foods

Anyone can get gout, but it's most common in men older than 40. In women, it is most likely to develop after menopause. Gout occurs in about one in 100 people over all, but in as many as 6% to 7% of older men. Being overweight and drinking excessive amounts of alcohol increase your risk for gout. Research suggests that men who eat generous amounts of red meat and seafood are more prone to gout. Those who eat more low-fat dairy products are less likely to be affected.

To diagnose gout, doctors measure uric acid levels in the blood and take a sample of fluid from the joint to look for uric acid crystals under a special microscope. But uric acid levels aren't always elevated during an attack, and many people with high levels never develop gout. Some people develop lumpy deposits made of sodium urate (called tophi) around the joints.

Treatment usually involves NSAIDs (see Table 2), but not aspirin, which can raise uric acid levels. People who can't take NSAIDs or who aren't helped by them may take a corticosteroid, either in pill form or by injection.

Rarely, people take drugs to lower uric acid levels in their blood. These include probenecid (Benemid, Probalan) to increase urinary excretion of uric acid, and allopurinol (Zyloprim), febuxostat (Uloric), and pegloticase (Krystexxa) to reduce the body's production of uric acid.

Pseudogout

As its name suggests, pseudogout is similar to gout, except that the crystals in the joints are made of calcium pyrophosphate dihydrate. The condition is often referred to as calcium pyrophosphate deposition disease, abbreviated as CPDD. Like gout, pseudogout causes redness, heat, and swelling in one or more joints, including those in the wrists and knees. The body attacks the crystals, which can cause swelling that may damage nearby cartilage.

  • Jolts of pain in the affected joint
  • Redness, warmth, and swelling in the affected joint

About 3% of people in their 60s develop pseudogout, although not all of them will have attacks. No one knows why some people develop these crystals, but they may result from an abnormality in the cartilage cells or connective tissue. Genes may also have an influence, and people with certain other medical conditions, including hypercalcemia (excessive calcium in the blood), hypothyroidism (low activity of the thyroid gland), and hemochromatosis (excess iron in the blood), are more prone to the problem.

Samples of joint fluid can help doctors diagnose pseudogout, and x-rays may reveal the calcium deposits in the joint. Drug treatments for a sudden attack of pseudogout are the same as those for gout: NSAIDs and corticosteroids. Sometimes removing joint fluid by needle aspiration improves the condition without additional treatment.

Many people with chronic, painful conditions like arthritis who don't get complete relief from conventional therapies turn to alternative treatments. As with any therapy, some people find that certain treatments work well for them, while others find little or no benefit. Talk with your physician to decide which approaches might work best for you, and consult a licensed, certified practitioner for specific treatment and guidance. The discussion below does not constitute an endorsement of any of these treatments.

Yoga. A 2011 review of 11 studies of yoga for treating arthritis suggests that yoga helps ease symptoms such as tender, swollen joints; pain; and disability. One small study of people with hand osteoarthritis found that yoga helped decrease pain and tenderness and increase finger mobility. Several types of yoga classes are available in most communities; be sure to choose one with a gentle style, ideally taught by an instructor familiar with therapeutic uses of yoga.

Acupuncture and acupressure. These ancient Chinese therapies have become popular for treating pain-related conditions, and some studies have shown acupuncture to be effective for some forms of pain. A 2013 analysis also indicates that the therapy can be useful in the treatment of gout. However, there are no specific studies demonstrating the effectiveness of acupuncture for treating hand pain.

Dietary supplements. A number of vitamins, minerals, and other substances are sold as remedies for arthritis. Because these products are classified as dietary supplements, they are not scrutinized for effectiveness and purity by the FDA. The following list, from the National Center for Alternative and Complementary Medicine, includes substances that have been tested for various forms of arthritis, with any known benefits, risks, and side effects:

  • Cat's claw. Liquid extracts of this woody vine show some possible benefit in osteoarthritis and rheumatoid arthritis. Rare side effects include nausea and vomiting.
  • Evening primrose oil. Extracted from the seeds of evening primrose flowers, this oil may be useful for rheumatoid arthritis. Mild gastrointestinal problems are a possible side effect.
  • Glucosamine and chondroitin sulfate. Although limited research has been conducted on glucosamine and chondroitin sulfate for osteoarthritis of the hand, a small trial done in 2011 showed that the supplements may have promise. The people who used the treatment reported less pain and morning stiffness and increased hand function over the individuals in the control group.
  • Omega-3 fatty acids. Some evidence suggests these fatty acids, found in fish oil, help curb inflammation in rheumatoid arthritis. Mild side effects include belching, bad breath, and other minor gastrointestinal problems.

Lupus

An autoimmune disease related to rheumatoid arthritis, lupus can affect various parts of the body, especially the skin, blood, and kidneys, as well as the joints—including multiple joints in the hand and wrist. Also called systemic lupus erythematosus (SLE), the disease affects women about eight to 10 times as often as men, most commonly between the ages of 18 and 45. Lupus-related arthritis in the hands tends to cause less swelling and actual joint damage than rheumatoid arthritis, but it may affect similar joints and feel the same.

  • Swollen, achy joints
  • Fever (100º F or higher)
  • Prolonged or extreme fatigue
  • Rashes

Some people with lupus develop hand deformities similar to those seen in rheumatoid arthritis, such as ulnar deviation and swan-neck deformities (see Figure 3). It can be hard to diagnose because there isn't a specific set of symptoms that occurs in everyone with the disease. The workup may include several different blood tests, as well as urine analysis, chest x-rays, and heart tests. Medical treatments for lupus include painkillers (see Table 2) as well as some drugs used to treat rheumatoid arthritis, such as methotrexate and hydroxychloroquine, an antimalaria drug (see Table 3).

Scleroderma

This autoimmune, rheumatic disease commonly affects the hands and fingers. Derived from the Greek words meaning "hard skin," scleroderma is also a connective tissue disease, meaning it affects major substances in the skin, tendons, and bones. It can be either localized (affecting limited areas of the skin, muscles, and bones) or systemic (causing more widespread skin changes and sometimes damaging the lungs, heart, and kidneys). It is quite rare, with only 10 to 20 new cases diagnosed per million people each year, mostly in women.

  • Hard, thickened skin that appears shiny and may lose hair
  • Swollen, puffy fingers and toes with poor blood flow and extreme sensitivity to cold
  • Ulcers or sores on fingers
  • In some cases, digestive, heart, lung, or kidney problems

People with scleroderma often have some or all of the symptoms that doctors refer to as CREST, which stands for the following:

  • Calcinosis: the formation of calcium deposits (visible on x-rays) in connective tissues, usually in the fingertips, face, and trunk, and on the skin above the elbows and knees. Painful ulcers may form where the deposits break through the skin.
  • Raynaud's syndrome: a condition that occurs when small blood vessels in the hands or feet contract in response to cold or anxiety (see "Cold hands: Is it Raynaud's syndrome").
  • Esophageal dysfunction: a condition caused by muscle problems in the esophagus (the tube that connects the throat and stomach), making swallowing difficult and sometimes causing chronic heartburn.
  • Sclerodactyly: thick, tight skin on the fingers, stemming from too much connective tissue within skin layers. Bending or straightening the fingers becomes difficult, and the skin may become shiny, dark, and hairless. The fingertips become tapered.
  • Telangiectasias: small red spots on the hands and face caused by the swelling of tiny blood vessels, which are not painful but may be unsightly.

Doctors also rely on blood tests, and possibly skin biopsies, to confirm a diagnosis of scleroderma. But such tests aren't definitive. Scleroderma symptoms vary and may come and go, especially in milder cases, making the disease difficult to diagnose.

Because there is no cure for scleroderma, treatments are meant to relieve symptoms. For example, blood pressure drugs that help widen blood vessels can help ease Raynaud's syndrome, and acid-lowering drugs can ease heartburn symptoms. NSAIDs or other painkillers help treat muscle pain. Hand therapy for scleroderma includes stretching and range-of-motion exercises, gentle massage to prevent joint contractures, paraffin treatments to soften skin, and help with modifying routine activities to limit stress on tender joints and relieve joint pain and swelling (see "Getting a grip: Handy gadgets and advice").

Psoriatic arthritis

This uncommon type of arthritis is related to psoriasis, a chronic skin condition marked by thick, red patches of skin covered with silvery scales. About a quarter of people with psoriasis develop psoriatic arthritis. In most cases, the skin condition is diagnosed first, but the arthritis may occur before the first signs of psoriasis, and some people with the condition have no skin lesions at all. Psoriatic arthritis can strike at any age but usually occurs between the ages of 20 and 50.

  • Joint swelling, stiffness, and pain in one or more joints
  • Pitting of the fingernails and toenails
  • In some cases, silver or gray scaly spots on the scalp, elbows, knees, or lower spine

The condition often affects the fingernails, causing small indentations (pitting) or lifting of the nails. As with all types of arthritis, joint swelling, stiffness, and pain are common; unlike rheumatoid arthritis, psoriatic arthritis usually affects only a few joints and tends to be asymmetric (that is, joints on both sides of the body are not necessarily affected similarly). Diagnosis is based on the person's history of psoriasis; physical examination of the skin, nails, and joints; x-rays; and, in some cases, joint fluid tests. Treatments for psoriatic arthritis include those used for rheumatoid arthritis, such as NSAIDs, steroids, and DMARDs (see Table 1, Table 2, and Table 3). Hand therapy treatments include reducing activity, protecting the joint, controlling swelling, improving range of motion, and learning gentle stretching and strengthening techniques.

If your fingers turn ghostly white and numb when exposed to cold, you may have Raynaud's syndrome. A common condition (it affects up to one in 10 people, most of them women), Raynaud's is an exaggeration of the body's normal response to cold. It usually affects the hands and feet and, less often, the nose, lips, and ears. Many people are extremely sensitive to the cold, but unless your extremities actually change color—to either white from lack of blood or blue from poorly oxygenated blood—you don't have Raynaud's.

When exposed to cold, the body normally slows its loss of heat and tries to preserve its core temperature. Blood vessels near the surface constrict, redirecting blood flow deeper into the body. In Raynaud's, this process is more extreme and can occur even with a fairly small decrease in air temperature.

An episode of Raynaud's begins when the blood vessels supplying the fingers and toes contract spasmodically, hampering the flow of oxygen-rich blood to the skin. Some of these vessels even collapse. The skin becomes pale and cool, sometimes blanching to a stark white color. The affected tissues may become numb and cold. A key feature of Raynaud's is that it is reversible. When the blood vessels finally relax and blood flow resumes, the skin becomes warm and flushed—and very red. The fingers or toes may throb or tingle.

Some people with Raynaud's have other health problems, usually connective tissue disorders such as scleroderma or lupus. Your doctor can determine this by doing a physical exam, asking you about your symptoms, and taking a few blood tests. But most of the time, there is no underlying medical problem.

The best treatment for Raynaud's is prevention, mainly by avoiding sudden and unprotected exposure to cold temperatures. Before you head outside into the cold, put on gloves and warm footwear, but also bundle up your entire body and head. Keeping your whole body warm helps prevent the reflexive constriction of blood vessels in your skin. You may want to wear gloves when reaching into your freezer, if you find that triggers the problem. Even exposure to air conditioning may be troublesome for people with Raynaud's.

It's also a good idea to avoid things that cause your blood vessels to constrict. Smoking is one such aggravating factor. Certain medications may also constrict the blood vessels; these include amphetamines, cold and allergy formulas that contain phenylephrine or pseudoephedrine, and migraine drugs that contain ergotamine. Stressful events may also provoke an episode of Raynaud's.

Relaxation techniques can help avoid stress-induced episodes. Thermal biofeedback, which trains people to self-regulate their finger temperature, also shows some promise in treating Raynaud's. This technique uses sensors placed on the fingers that feed temperature information to a video screen, so you can monitor your progress.

Your doctor may prescribe a medication that relaxes the blood vessels, usually a calcium-channel blocker. If it's not effective, other blood pressure drugs that open up blood vessels may help. Two small studies suggest that drugs used to treat erectile dysfunction (which work by expanding blood vessels and boosting blood flow) may ease Raynaud's symptoms. You may not need to take these drugs all the time, but only during the cold season, when Raynaud's tends to be worse.

Once a Raynaud's episode starts, it's important to get warm as quickly as possible. Try soaking your hands in lukewarm (about 105º F) water, or put them under your armpits or in another warm area. But don't put your hands, feet, or face on a heater or anything else that could scald or otherwise injure you.

Next: Advances in artificial joints for the hand

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