What is Scleroderma?

The term “scleroderma” refers to a group of related conditions primarily characterized by similar manifestations. Fibrosis (excessive connective tissue formation, almost always resulting in hardening of the skin), vascular damage, and autoimmune responses are all common in scleroderma. The cause of scleroderma is not well understood, and there are no drugs to cure the underlying condition.

Scleroderma can either be localized or systemic. Systemic scleroderma, also called systemic sclerosis, is much more severe; it can cause damage to internal organs unlike the localized condition.

Several natural interventions such as epigallocatechin gallate (EGCG) from green tea and N-acetylcysteine may be helpful for addressing the driving factors behind the disease’s progression.

What are the Risk Factors for Scleroderma?

• Genetic predisposition
• Exposure to some industrial chemicals

Note: The exact cause of scleroderma is unknown.

What are the Signs and Symptoms of Scleroderma?

• Skin changes, including hardening, swelling, and abnormal lightening or darkening
• Raynaud’s phenomenon, in which cold temperature or stress causes vasoconstriction. The affected limb(s) or digit(s) usually turn white with lack of blood flow, then blue with poor oxygenation, and then red when blood flow resumes.
• Systemic sclerosis can cause other symptoms involving internal organs—coughing due to lung involvement, arrhythmia due to heart involvement, digestive problems, or scleroderma renal crisis if kidneys are affected.

What are Conventional Medical Treatments for Scleroderma?

Note: There is no known cure for scleroderma. Conventional treatments generally are palliative and aim to alleviate symptoms and reduce complications.

• Drugs to improve blood flow for Raynaud’s phenomenon
• Immunomodulatory or suppressing drugs for skin or lung fibrosis
• Antacids or drugs that reduce stomach acid for digestive problems
• Dialysis or blood pressure lowering drugs for renal crisis

What are New Research Directions for Treating Scleroderma?

• Studying epigenetic or other methods to reduce proliferation and/or activation of fibroblasts
• Drugs that destroy immune B cells or inhibit their production

What Dietary and Lifestyle Changes Can Help Manage Scleroderma?

• Avoid cold temperatures and emotional stress to reduce Raynaud’s phenomenon attacks.
• Exercise to enhance blood circulation and improve endothelial function.
• Eat plenty of fresh fruits and vegetables to avoid malnutrition and reduce oxidative stress.

What Natural Interventions Can Help Manage Scleroderma?

• Gamma-linolenic acid (GLA). GLA, an omega-6 fatty acid found in evening primrose oil, can reduce episodes of Raynaud’s phenomenon. It also may diminish pain and improve skin texture in those with scleroderma.
• S-adenosylmethionine (SAMe). SAMe has many uses, and in scleroderma patients it has been shown to improve skin quality.
• N-acetylcysteine (NAC). NAC can reduce the severity of Raynaud’s phenomenon, diminish lung-related complications of scleroderma, and improve vascular function of the liver and kidneys.
• Vitamin E. Vitamin E can be helpful in several autoimmune disorders, including scleroderma. Several symptoms of scleroderma have been reported to respond well to vitamin E.
• Green tea. Green tea and one of its active constituents, epigallocatechin gallate (EGCG), have beneficial effects on the endothelium. Evidence suggests EGCG suppresses tissue fibrosis.
• Gotu kola. Gotu kola is an herb that has many skin-healing properties. In one study, patients treated with gotu kola saw improvements in skin quality, vascular health, and general condition.
• Other natural interventions such as curcumin, 4-aminobenzoic acid, vitamin D, and melatonin may be beneficial to patients with scleroderma.

The term “scleroderma” encompasses a spectrum of complex and variable conditions primarily characterized by 3 major phenomenon: abnormal, excess formation of connective tissue (fibrosis), vascular alterations, and an autoimmune response (Gabrielli 2009; A.D.A.M. 2013; Derk 2003; Balbir-Gurman 2012; Varga 2008). Scleroderma spectrum disorders share the common feature of hardening or thickening of the skin, but other manifestations can vary greatly between patients. Although the cause of scleroderma is not understood, the hallmark of scleroderma is fibrosis, which is a process similar to the formation of scar tissue; fibrosis is primarily brought about by inflammation. No cure currently exists for scleroderma (Gabrielli 2008; Gomer 2008).

There are 2 primary types of scleroderma:

• The less severe form is called localized scleroderma. It is limited to the skin and underlying muscles, joints, and sometimes bones; it does not affect internal organs. In some cases, localized scleroderma may resolve on its own (Mayo Clinic 2010; NIAMS 2012; Gabrielli 2009; Clemens 2003; Klein-Weigel 2011; Hawk 2001; Takehara 2005). There are about 27 new cases of localized scleroderma per million people per year (Peterson 1997).
• The more widespread and severe form is called systemic scleroderma (also known as systemic sclerosis). This form is progressive and occurs throughout the body, affecting internal organs as well as the skin (Chatterjee 2010). It may affect the connective tissue of the lung, kidney, heart, and other organs, as well as blood vessels, muscles, and joints (Hawk 2001; Heinberg 2007). There are 2 subtypes of systemic sclerosis: limited cutaneous systemic sclerosis (historically known as CREST syndrome) and diffuse cutaneous systemic sclerosis (Jimenez 2012; Gabrielli 2009). Limited cutaneous systemic sclerosis typically affects the skin on limited areas of the body, such as the fingers, hands, or the face and is less likely to involve internal organs early in disease progression. Diffuse cutaneous systemic sclerosis, which may start suddenly and spread over much of the body, is associated with a poorer prognosis  (Hughes 2012). There are about 19 new cases of systemic sclerosis per million people per year (Jimenez 2012).

Conventional management strategies for scleroderma are limited to interventions that control specific symptoms; no drug has been developed that successfully treats the underlying cause(s) of scleroderma (Hinchcliff 2008). On the other hand, natural strategies may offer a means of directly targeting fibrosis, a destructive process that involves the formation of tough connective tissue through inflammatory pathways and is a central driving force behind scleroderma progression. Natural constituents like epigallocatechin gallate (EGCG) from green tea, N-acetylcysteine, and vitamin E may help preserve tissue integrity in scleroderma sufferers (Chang 2013; Rosato 2009b; Fiori 2009; de Souza 2009). Moreover, maintaining adequate blood levels of vitamin D may be an important consideration for individuals affected by scleroderma, since studies show it can directly modulate signaling pathways that contribute to fibrosis (Slominski 2013; Arnson 2011).

In this protocol you will learn about the different types of scleroderma and how they are diagnosed and treated. Future research directions will be explored, and a variety of scientifically studied natural interventions will be reviewed. Some important dietary and lifestyle considerations will be presented as well.

Scleroderma is primarily the consequence of 3 major factors: blood vessel damage, an autoimmune response, and fibrosis. In many ways, these factors create a vicious cycle, thus the disease is typically progressive; this is especially so for systemic sclerosis (Gabrielli 2008; Gomer 2008).

Blood Vessel Damage

Small blood vessels are especially prone to the damage and dysfunction caused by scleroderma. Vascular dysfunction is mostly the result of inflammation and fibrosis, which cause blood vessels to become “stiff” and disrupt their ability to expand and contract (Varga 2008). A major hallmark of vascular damage that occurs in scleroderma is endothelial dysfunction. The endothelium is the delicate innermost lining of blood vessels (Varga 2008; Deanfield 2005; Patel 2001; Gabrielli 2009). In severe cases of systemic sclerosis, dramatic vascular dysfunction can be life threatening (Hummers 2008).

In addition, scleroderma is associated with increased deposition of calcium in blood vessels. In one study, systemic sclerosis patients were found to have an 11-fold increased risk of moderate-to-severe calcification in the arteries that supply the heart (Mok 2011). Moreover, autopsy investigations of systemic sclerosis patients have found extensive calcification of small blood vessels that supply the brain (Heron 1998). 

Inflammation and Autoimmune Response

Inflammatory and autoimmune reactions also contribute to the tissue damage and dysfunction seen in scleroderma. Blood vessel alterations lead to an inflammatory response within the endothelium. In turn, damaged endothelial cells release inflammatory signaling molecules that recruit immune cells, in particular CD4+ helper T-cells, to the blood vessel walls. The presence of excessive inflammatory mediators serves to reinforce the continued deterioration of blood vessel integrity and subsequent generation of more inflammation and fibrosis. Autoimmunity also contributes to inflammatory damage of the blood vessels, though it is not known with certainty if an autoimmune response is the key initiating factor in scleroderma (Varga 2008; Castro 2010; Gabrielli 2009).

Fibrosis

Fibrosis describes the hardening or stiffening of tissues that are normally soft and malleable. It occurs as a result of over activation of specialized cells called fibroblasts, which produce collagen and the "glue" (called extracellular matrix) that holds tissues together. Connective tissue is made of collagen and other proteins, so when excessive collagen is produced via overactivation of fibroblasts, connective tissue can accumulate abnormally, thus contributing to tissue fibrosis. DNA damage and pro-inflammatory oxidative stress, which is increased in patients with scleroderma, is proposed to be a major driving force behind fibroblast overactivation (Gabrielli 2012; Avouac 2010).

Fibrosis is responsible for the most obvious symptom of scleroderma – hardening of the skin. However, fibrosis of organs and blood vessels can occur as well and this contributes to some of the systemic complications associated with scleroderma.

The exact cause of scleroderma is unknown. However, several factors are thought to influence risk, including environmental exposures and genetic susceptibility (ie, family history) (Castro 2010; Agarwal 2010a,b; Dieude 2011). For example, exposure to chemicals like polyvinyl chloride (used in the plastics industry), industrial solvents (such as paint thinners), and silica may trigger or exacerbate scleroderma (Barnes 2012; Varga 2008; Mora 2009; NIAMS 2010). Also, over 30 genes and gene regions are known to influence scleroderma susceptibility; most of these genes are related to the immune system (Mayes 2012).

The manifestations of scleroderma are variable and dependent upon the extent of systemic involvement. For example, localized scleroderma may affect only the fingers and cause moderate hardening of the skin, whereas severe systemic sclerosis can compromise internal organs such as the lungs and kidneys and be life threatening. Some of the more prominent features of scleroderma include:

Skin Changes

Skin manifestations of scleroderma include puffy and swollen fingers, hands, and toes, along with thickening and hardening of the skin, which can also affect the face and trunk. The areas of the skin affected often appear shiny and hair loss occurs in affected regions as well; skin may also appear abnormally light or dark. Tightening of the skin on the face can give a mask-like appearance. Sometimes, patients develop ulcers on their fingertips or toes, which can lead to scarring. In addition, small blood vessels just beneath the top layer of the skin may become dilated and more visually pronounced, called telangiectasias (Gaby 2006; Chatterjee 2010; A.D.A.M. 2013). 

Raynaud's Phenomenon

Raynaud's phenomenon is present in up to 95% of patients with scleroderma (Hinchcliff 2008; Simonini 2000; NIAMS 2010). Raynaud’s phenomenon is a complex vascular disorder in which blood vessels, particularly those in the fingers and toes, or rarely the tongue, nose, ears, lips, or nipples, overreact to cold temperature or emotional stress (Mayo Clinic 2011; Herrick 2012; Martínez 2011). The blood vessels constrict (ie, vasoconstriction), reducing blood flow to the affected extremity. This results in numbness while blood flow is reduced and tingling and/or pain as blood flow returns to the affected area (Herrick 2012; Martínez 2011). These attacks may last from minutes to hours, and the intensity of discomfort may vary from mild to severe (Malenfant 2011; NCBI 2011; Martínez 2011). In severe cases, prolonged oxygen deprivation can lead to tissue death in the affected extremities (Herrick 2012). More information is available in the Raynaud’s Phenomenon protocol.

Internal Organ Involvement

Systemic sclerosis can affect multiple internal organs. However, the disease does not progress in exactly the same way in all patients. Some significant manifestations include (Balbir-Gurman 2012):

• Symptoms due to lung involvement include dry cough and shortness of breath (A.D.A.M. 2013). Cough is usually correlated with the degree of fibrosis in the lungs (Theodore 2012). Lung function tests are abnormal in as many as 80% of scleroderma patients (Jimenez 2012).
• Heart and cardiovascular complications are caused by scarring and weakening of the heart muscle, and include myocarditis and arrhythmia (NIAMS 2012). In addition, patients with systemic sclerosis have significantly increased risk of atherosclerosis, heart attack, stroke, and peripheral vascular disease compared to healthy individuals (Man 2013; Au 2011). Thus, individuals with systemic sclerosis are also encouraged to review Life Extension’s Atherosclerosis and Cardiovascular Disease protocol.
• A serious complication, when the kidneys are affected, is scleroderma renal crisis. This may lead to abrupt onset high blood pressure and progressive kidney failure (NIAMS 2012).
• Digestive problems include difficulty swallowing, esophageal reflux, bloating, diarrhea, constipation, and fecal incontinence (A.D.A.M. 2013). 

Physicians may suspect scleroderma based on presentation of the characteristic signs and symptoms mentioned previously. Although there is no specific test for scleroderma, a diagnostic workup may include a detailed medical history, laboratory findings, and skin biopsy (NIAMS 2010; Nashel 2012; Khoo 2011).

Doctors may test for autoantibodies against topoisomerase (Scl-70), centromere-associated proteins, and nuclear antigens (ANA); this can aid in diagnosis but must be supported by other evidence (Grassegger 2008). Rheumatoid factor, another autoantibody, may be present in some patients as well. Abnormalities on routine lab tests may help identify involvement of specific organs (Ferri 2013). Elevated levels of the inflammatory marker C-reactive protein (CRP) have been associated with worse outcomes in some patients and may help influence treatment decisions (Muangchan 2012). Diagnosing scleroderma can be difficult due to the significant variability in disease presentation.

Scleroderma has no known cure. There are a variety of medications that can help palliate symptoms and reduce complications of scleroderma, but medications that modify the course of the disease are lacking (Kowal-Bielecka 2009; Opitz 2011; Baumhakel 2010; Gayraud 2007).

Side effects of conventional treatment vary with medication, and may include fluid buildup in the feet, constipation and gastrointestinal disturbances, fatigue, flushing, allergic symptoms, gingivitis (inflammation of the gums), and erectile dysfunction. Steroids such as prednisone are frequently used for their anti-inflammatory action. However, steroids have significant side effects, including loss of bone density and weight gain.

Despite intensive study for several years, many questions about scleroderma remain unanswered. This is reflected by the fact that the mortality rate for scleroderma patients has not changed significantly over the past 40 years (Elhai 2012). However, as scientists continue to piece together the biologic framework of scleroderma, there is hope that therapeutics that target pathways leading to tissue fibrosis can be developed resulting in improved patient outcomes (Leask 2012).

Much of scleroderma research now focuses on developing ways to reduce the proliferation and/or activation of fibroblasts (Jungel 2011). Avenues being pursued include epigenetics and various methods of modifying growth and signaling pathways that lead to fibroblast activation (Gordon 2010). Unfortunately, some of these strategies have proved ineffective or only able to provide marginal benefits in clinical trials (Prey 2012).

One strategy that has shown some promise is suppression of the immune system with drugs that destroy B-cells or inhibit their production. Examples of drugs in this category include rituximab (Rituxan®) and mycophenolate mofetil (CellCept®). In preliminary trials, these interventions have shown some benefit (Le 2011; Mendoza 2012; Daoussis 2012). However, larger clinical trials are needed to more thoroughly assess the viability of this approach.

Other ongoing research efforts are evaluating immunosuppression followed by transplantation of autologous peripheral blood stem cells, and high-dose cyclophosphamide (NCT00114530; NCT00501995).

Several dietary and lifestyle considerations are relevant for people with scleroderma.

Since exposure to cold may trigger episodes of Raynaud’s phenomenon in scleroderma patients, taking steps to keep warm such as wearing gloves when venturing out in cold temperatures may be helpful (Maricq 1996; Herrick 1998; Ihler 2003).  More information is available in the Raynaud’s Phenomenon protocol.

Exercise enhances blood circulation, which may be beneficial for scleroderma that primarily affects hands and feet. It has also been shown to improve muscle strength and function as well as aerobic capacity in patients with systemic sclerosis (Pinto 2011; Semenova 1973). Exercise also improves endothelial function and lowers blood pressure, which may provide significant benefit to people with scleroderma, since blood vessel dysfunction is a hallmark of the disease (Tjonna 2011; Tinken 2008; Black 2008).

Scleroderma patients also often have poor nutritional status, with over 28% of the patients having a medium or high risk for malnutrition (Baron 2009; Krause 2010). Reduced levels of the antioxidants vitamin C, vitamin E, beta-carotene, and selenium have been reported among individuals with scleroderma and Raynaud's phenomenon (Simonini 2000). Because scleroderma is associated with increased oxidative stress, eating plenty of fresh fruit and vegetables is important (Gabrielli 2008; Sfrent-Cornateanu 2008).

Evening Primrose Oil and Gamma-linolenic acid (GLA)

GLA is an omega-6 fatty acid available from borage oil, evening primrose oil or black currant seed oil. It serves as a precursor for an anti-inflammatory signaling molecule called prostaglandin E1 (Gaby 2006).

In a randomized controlled trial, patients with Raynaud’s phenomenon (with or without scleroderma) were given 6 g of evening primrose oil per day or placebo for 8 weeks. After 6 weeks of treatment, the evening primrose oil group experienced significantly fewer episodes of Raynaud’s phenomenon than those in the placebo group. All of the scleroderma patients noticed improvement; the authors noted this was similar to their previous results using a prostaglandin E1 infusion (Belch 1985). Another study gave scleroderma patients 1 g evening primrose oil three times daily. After one year, patients experienced less pain in their hands and feet, healed ulcers, and improved skin texture (Strong 1985).

S-adenosylmethionine (SAMe)

Well known for its use in mood modulation, liver disease, and osteoarthritis, SAMe may also be of benefit in scleroderma (Bottiglieri 2002). One study found that intravenous administration of 600 mg SAMe per day for two months, followed by oral ingestion of 400 mg 3 times daily, significantly improved skin quality in patients with systemic sclerosis. After four months, 50% of patients in the study showed a significant improvement in skin texture; one patient even experienced improvement in walking abilities due to increased malleability of skin on the feet and ankles and 4 subjects displayed improved skin fold thickness, another marker of skin texture quality. In 3 patients who underwent skin biopsy, a significant reduction in skin thickness was observed (Oriente 1985).

N-acetylcysteine (NAC)

The antioxidant N-acetylcysteine (NAC) has shown promise in reducing the severity of Raynaud’s phenomenon in people with scleroderma. Several studies have shown that, in patients with Raynaud’s phenomenon as a result of systemic sclerosis, intravenous infusion of NAC effectively increases blood flow to the fingers due to its blood vessel dilating effect; it also reduces the severity and frequency of the episodes of Raynaud’s phenomenon (Salsano 2005; Sambo 2001; Rosato 2009c). NAC has also been shown to reduce lung-related complications of scleroderma (Failli 2002). An open-label trial in which 40 patients were administered intravenous NAC for 5 hours found that vascular function in the kidneys improved following NAC treatment in patients with systemic sclerosis whose disease was not severe (Rosato 2009b). Similarly, systemic sclerosis patients with limited disease severity showed improved markers of liver blood flow following the same intravenous NAC treatment (Rosato 2009a).

Vitamin E

Vitamin E has been shown to be useful in the management of a number of autoimmune diseases in which the skin is affected, including scleroderma (Ayres 1978). Various manifestations of scleroderma, including Raynaud’s phenomenon, were reported to respond well to vitamin E; the vitamin E doses to achieve these effects ranged between 200 and 1200 IU per day (Gaby 2006). Moreover, in some cases, vitamin E was also applied topically. For example, one study showed that topical application of vitamin E gel hastened healing of digital ulcers in systemic sclerosis patients (Fiori 2009).

In a clinical trial, vitamins C and E were combined with cyclophosphamide and compared to cyclophosphamide alone in patients with systemic sclerosis. The combination of the two antioxidant nutrients and cyclophosphamide led to less progressive skin thickening and a trend toward improved lung function compared to treatment with only cyclophosphamide (Ostojic 2011). A 24-week trial found that coadministration of the anti-inflammatory and vasodilating drug pentoxifylline with vitamin E reduced skin fibrosis in patients with systemic sclerosis (de Souza 2009).

Green Tea

Several studies have shown that green tea, and one of its main active constituents, epigallocatechin gallate (EGCG), has beneficial effects on the endothelium – the delicate inner lining of blood vessels, which is compromised in scleroderma (Shenouda 2007; Widlansky 2007; Alexopoulos 2008). Evidence also suggests that EGCG can suppress tissue fibrosis by inhibiting a signaling pathway that promotes excessive accumulation of collagen (Park 2008).

Experimental studies are strongly suggestive of the therapeutic potential of green tea EGCG in treating autoimmune diseases (Wu 2011). In addition, a laboratory study found that EGCG decreased collagen secretion by fibroblasts. The authors concluded that their results “suggest that the antioxidant, EGCG, can reduce ECM [extracellular matrix] production, the fibrotic marker CTGF [connective tissue growth factor] and inhibit contraction of dermal fibroblasts from SSc [systemic sclerosis] patients” (Dooley 2010). Numerous other studies have noted multiple antifibrotic actions of green tea constituents (Xiao 2013; Chang 2013; Tsai 2013; Cai 2013). While there is a need for future human clinical trials to confirm this, bearing in mind the well-documented cardiovascular effects of green tea and EGCG in humans, patients with scleroderma and other autoimmune diseases may benefit from supplementing with green tea EGCG (Wu 2011).

4-Aminobenzoic acid (PABA)

Sometimes referred to as a member of the B-vitamin family, PABA is a water-soluble organic compound that has been studied as far back as the 1940s as a remedy for scleroderma (Zarafonetis 1948). Case reports of the effects of PABA in scleroderma patients are dispersed throughout the scientific literature over the decades leading up to the 1980s, at which point more rigorous analyses were published (Meyers 1977; BMJ 1968; Gougerot 1951). Evidence from retrospective studies indicate PABA is associated with several benefits for scleroderma patients, including improved survival, skin softening, and better maintenance of lung function over time (Zarafonetis 1988a,b; Zarafonetis 1989). Unfortunately, in 1994, a double-blind, placebo-controlled trial failed to show that PABA was superior to placebo for treating skin manifestations of scleroderma (Clegg 1994). Despite the results of this study, case reports of benefits in skin conditions related to scleroderma continue to be published (Gruson 2005). Although the mechanism(s) by which PABA may modify scleroderma are unclear, one study showed that the compound was able to inhibit growth of fibroblasts derived from scleroderma patients (Priestley 1979). Additional studies are needed to evaluate PABA as a treatment for scleroderma.

Melatonin

Melatonin, also known as the "sleep hormone," is produced and secreted by the pineal gland during nighttime (Pandi-Perumal 2006). Melatonin is involved in sleep regulation, as well as in a number of other cyclical bodily activities.

Melatonin has several beneficial effects on the endothelium that are directly relevant for scleroderma: it scavenges free radicals, activates antioxidant defense enzymes, reduces blood pressure, and increases nitric oxide bioavailability (Scheer 2004; Rodella 2013). Its ability to protect against endothelial damage, blood vessel constriction, platelet aggregation, and the accumulation of excessive amounts of white blood cells in tissues (leukocyte infiltration) might explain the beneficial effects of supplementation that were described in patients with scleroderma (Rodella 2013). In a study that included 5 patients, supplementation of melatonin in combination with vitamin E and ACTH, a hormone secreted by the anterior pituitary gland and important for the health of the neuroimmunoendocrine system, achieved a partial response in all patients after one month of treatment, and disease progression was stopped in all five patients when the treatment was continued further (Todisco 2006). A laboratory study investigated the effect of melatonin on human skin fibroblasts (connective tissue cells), and reported that it caused an over 80% inhibition of the growth and multiplication of fibroblasts derived from the skin of healthy individuals and scleroderma patients (Carossino 1996).

Gotu kola (Centella asiatica)

Gotu kola (Centella asiatica) is an herb found in most tropical and subtropical countries, including India, South Africa, Madagascar, and Eastern Europe (Gohil 2010). Gotu kola alleviates microcirculatory problems and may help inflammatory skin conditions, such as lupus, varicose ulcers, eczema, atopic dermatitis, and psoriasis (Belcaro 2011; Gohil 2010). In addition to being an anti-inflammatory, gotu kola is also an antioxidant that can help control oxidative stress associated with inflammation and/or infections (Belcaro 2011; Gohil 2010). It also aids wound healing and is used for scar management (Maquart 1999; Bonte 1994; Widgerow 2000; Paocharoen 2010; Belcaro 2011).

Gotu kola has been used for localized and systemic scleroderma with positive results. After 6 months of supplementation in oral form with 30 mg/day (10 mg, three times a day), a study on 12 patients with systemic sclerosis showed a decrease of vascular disorders, hard lesions, hyperpigmentation, and improvement in the patients’ general condition. A beneficial response was also obtained with local application of gotu kola ointment on finger ulcers, and the therapy was well tolerated (Guseva 1998).

Curcumin

Curcumin is a major component of the spice turmeric. Turmeric has been used in Ayurvedic medicine to treat a wide range of conditions, and practitioners of alternative medicine often recommend curcumin as a treatment for inflammatory and autoimmune diseases (Aggarwal 2009,2011; Jurenka 2009). Moreover, curcumin has been shown in the last two decades to have potent immunomodulatory, neuroprotective, and anti-cancer effects (Jagetia 2007; Zhou 2011; Sharma 2005; Cole 2007; Jurenka 2009). Because scleroderma is a disease that involves exaggerated collagen deposition and excessive growth (proliferation) of fibroblasts, curcumin may be able to provide a therapeutic benefit through its ability to suppress the proliferation of fibroblasts (Tourkina 2004; Punithavathi 2003; Smith 2010). Laboratory studies reveal that curcumin suppresses transforming growth factor beta (TGF-β), a profibrotic signaling molecule implicated in the development of scleroderma (Song 2011). Another study found that curcumin caused cell death (apoptosis) in scleroderma lung fibroblasts but not in normal lung fibroblasts. The authors concluded “these observations suggest that curcumin may have therapeutic value in treating scleroderma…” (Tourkina 2004).

Vitamin D

Vitamin D is a precursor to the hormone calcitriol, which exerts a vast array of actions throughout the body. Calcitriol plays an especially prominent role in modulation of the immune system (Panichi 2003). Moreover, associations have been made between low blood levels of vitamin D and autoimmune and inflammatory disorders, including scleroderma (Agmon-Levin 2012; Vacca 2011).

In one study, scleroderma patients were more likely to be deficient in vitamin D compared to healthy control subjects. In addition, scleroderma patients with higher vitamin D levels had less extensive skin involvement than those with low levels. Higher vitamin D concentrations were associated with less skin fibrosis as well (Arnson 2011). These findings are in line with experimental evidence that suggests calcitriol and related vitamin D metabolites can modulate growth factor signaling, thereby reducing the propensity of fibroblasts to promote fibrosis (Slominski 2013).

Other clinical trials and case reports have shown that direct administration of calcitriol results in symptomatic improvement in scleroderma patients. In one small trial conducted on three patients with localized scleroderma, calcitriol administration for 7 months improved skin tightness and joint mobility (Hulshof 1994). Another trial showed oral calcitriol treatment considerably improved skin lesions in 5 of 7 children with scleroderma (Elst 1999). Similarly, in a trial conducted on 11 scleroderma patients, calcitriol treatment for up to 3 years was associated with significant improvements compared to baseline (Humbert 1993).

These findings give credence to the notion that maintenance of adequate vitamin D blood levels should be a priority for scleroderma patients. Life Extension suggests that most adults target an optimal 25-hydroxyvitamin D level of 50 – 80 ng/mL.