What is the treatment for Buerger's disease?

Treatment of Buerger's Disease

Complete tobacco cessation is the cornerstone and most effective treatment for Buerger's disease, and is essential to prevent disease progression and limb loss. 1, 2, 3

Diagnosis Confirmation

Before initiating treatment, confirm diagnosis using Shionoya's clinical criteria:

• History of tobacco use
• Onset before age 50
• Infrapopliteal arterial occlusions
• Either upper limb involvement or phlebitis migrans
• Absence of atherosclerotic risk factors other than smoking 4, 5

Treatment Algorithm

First-line Treatment:

1. Absolute tobacco cessation

   • Must include ALL tobacco products (cigarettes, smokeless tobacco, etc.)
   • Evidence shows substituting smokeless tobacco for cigarettes does not prevent disease progression 6
   • Patient education about direct relationship between tobacco use and disease progression

2. Pain management

   • Appropriate analgesia for ischemic pain
   • Consider neuropathic pain medications if indicated

3. Conservative measures for patients with claudication

   • Encourage walking for patients with claudication symptoms
   • Bed rest for patients with critical limb ischemia 4

Second-line Treatments:

1. Pharmacological options (limited evidence of efficacy):

   • Vasodilators such as alprostadil (prostaglandin E1) 3
   • Antiplatelet therapy may be considered

2. Interventional procedures (for severe cases):

   • Lumbar or thoracic sympathectomy for pain relief 5
   • Bypass surgery rarely an option due to distal nature of disease and lack of target vessels 4

Management of Complications:

1. Wound care for ulcerations

   • Appropriate dressings
   • Infection prevention and treatment with antibiotics when indicated

2. Amputation

   • Minor amputations for non-healing ulcers or gangrene
   • Major amputations only as last resort (reported in approximately 4% of cases) 5

Important Considerations

• Tobacco cessation is mandatory: Without complete cessation, all other treatments are likely to fail
• Disease can progress despite treatment: Even with tobacco cessation, some patients may require amputation
• Bypass surgery limitations: Traditional revascularization has limited success due to distal nature of disease 1, 4
• Associated conditions: Consider screening for and treating periodontitis, which has been associated with Buerger's disease in over 50% of patients 5

Monitoring and Follow-up

• Regular vascular assessment to monitor disease progression
• Vigilant skin inspection for early detection of ulcers
• Ongoing support for tobacco cessation
• Prompt treatment of any infections

Prognosis

With complete tobacco cessation, disease progression typically halts. However, existing damage is often permanent. Without tobacco cessation, progressive arterial occlusion typically leads to tissue necrosis, ulceration, and eventual need for amputation 2, 3, 4.