Digital Ulceration in Connective Tissue Disease: When Iloprost Alone Has Not Achieved Healing

This protocol applies to patients with secondary Raynaud's phenomenon presenting with digital ulceration or critical digital ischaemia in the context of connective tissue disease, where an earlier intravenous Iloprost regimen has not reached its clinical goals.

Clinical Scenario

Raynaud's phenomenon progresses to tissue damage — including digital ulceration and critical digital ischaemia — when it is secondary to an underlying cause, which in rheumatology practice typically means connective tissue disease. Management principles are shared across both digital ulceration and critical ischaemia presentations.

Previous Treatment — Failure Condition

Prior therapy: Iloprost intravenously

Goals not achieved: Digital ulcer healing, and reduction in the frequency and severity of Raynaud's phenomenon attacks. Failure to reach these targets is the trigger for escalation to this next-line protocol.

Next-Line Approach

The next step involves a combination approach — pairing intravenous prostanoid therapy with an additional oral agent — rather than continuing with intravenous prostanoid alone. The complete regimen, clinical algorithm, and full sequencing detail is available in the structured protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1177/1759720X17740074

RP only progresses to tissue damage when secondary to an underlying cause, which for the rheumatologists usually means a connective tissue disease.

These principles of management are very similar for both digital ulceration and critical ischaemia, and so will be considered together.

Intravenous prostanoid and sildenafil in combination.

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