skip to main content

Systemic sclerosis-associated digital ulcer disease — SCE Rheumatology MCQ

Instant feedback + full explanation. One question, done properly.

ModerateDermatologySystemic sclerosis-associated digital ulcer diseaseSCE Rheumatology

A 47-year-old man with limited cutaneous systemic sclerosis has severe digital vasculopathy despite smoking cessation, cold-avoidance measures, modified-release nifedipine 60 mg daily and sildenafil 20 mg three times daily. Over the past 12 months, he has developed seven new fingertip ulcers. His most recent ulcer required intravenous iloprost because of threatened tissue loss; it is now shallow and epithelialising, with no infection or persisting critical ischaemia. He has no pulmonary arterial hypertension. Liver biochemistry, haemoglobin and renal function are normal. Which additional pharmacological strategy is most appropriate specifically to reduce the number of new digital ulcers?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Commence bosentan

Bosentan is the best addition because the dominant problem is recurrent formation of multiple new systemic sclerosis-associated digital ulcers despite established oral vasodilator therapy. EULAR specifically recommends bosentan to reduce the number of new digital ulcers. Trials supporting its UK licence showed fewer new ulcers, with a greater effect in patients with multiple ulcers, but did not demonstrate accelerated healing of existing ulcers. Intravenous iloprost is highly plausible because it was appropriate for his recent threatened digit and is recommended for active digital ulcers or severe Raynaud phenomenon after oral treatment failure. However, the current ulcer is healing and the question asks specifically about prevention of further ulcers. Macitentan cannot be substituted as a class equivalent: trials in systemic sclerosis digital-ulcer disease were negative, so the recommendation remains specific to bosentan. Fluoxetine appeared in older guidance as an option for Raynaud phenomenon but is not recommended for prevention of digital ulcers in the current EULAR update. Clopidogrel has no established role in preventing systemic sclerosis digital ulcers and would require a separate antiplatelet indication. Bosentan requires appropriate hepatic monitoring and review of interactions after initiation.

Reference: EULAR recommendations for the treatment of systemic sclerosis: 2023 update (Published online 17 October 2024; journal issue 2025) — https://ard.bmj.com/content/early/2024/10/17/ard-2024-226430 Bosentan 62.5 mg Film-coated Tablets — Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/820/smpc