Initial Management of Tendon Friction Rubs in Systemic Sclerosis
Tendon friction rubs (TFRs) in systemic sclerosis should be treated with low-dose corticosteroids (≤10 mg daily) as the primary pharmacologic intervention, similar to the approach for inflammatory arthritis in SSc. 1
Clinical Significance and Risk Stratification
TFRs are a critical prognostic marker that demands immediate attention and aggressive monitoring:
Patients with TFRs have a >2-fold increased risk of developing scleroderma renal crisis, cardiac complications, and gastrointestinal disease, even after adjusting for other known risk factors. 2
TFRs are associated with reduced 5-year and 10-year survival rates in early diffuse cutaneous SSc (dcSSc). 2
TFRs are recognized as a risk factor for scleroderma renal crisis, alongside male sex, rapidly progressive skin involvement, and glucocorticoid use. 3, 4
TFRs are predictive of poor prognosis and indicate more aggressive disease requiring careful monitoring for serious internal organ involvement. 2, 5
Pharmacologic Management
Primary Treatment Approach
Corticosteroids at doses ≤10 mg daily are the recommended initial pharmacologic treatment for TFRs. 1
Methotrexate can be considered as an alternative or adjunctive therapy, particularly if there is coexisting inflammatory arthritis or early dcSSc requiring immunosuppression for skin sclerosis. 1
Additional Immunosuppressive Options
If corticosteroids alone are insufficient or if there are other manifestations requiring systemic therapy:
Mycophenolate mofetil is preferred when TFRs occur in the context of early dcSSc with skin sclerosis, especially if there is coexisting interstitial lung disease. 1, 6
Tumor necrosis factor inhibitors, tocilizumab, or abatacept may be considered if inflammatory arthritis is prominent alongside TFRs. 1
Non-Pharmacologic Management
Occupational Therapy Interventions
All patients with TFRs should receive occupational hand therapy including range of motion exercises, paraffin wax treatments, and devices to assist with activities of daily living. 1
Physical exercise and physiotherapy should be considered to improve functional impairment in SSc patients with musculoskeletal involvement. 3
Intensive Monitoring Protocol
Given the high-risk nature of TFRs, implement the following surveillance:
Regular blood pressure monitoring (both clinic-based and home monitoring) to detect early scleroderma renal crisis, particularly in patients with early dcSSc. 3
Baseline and serial assessment of cardiac function if arrhythmias or heart failure symptoms develop. 3, 4
Evaluation for gastrointestinal complications, as TFR-positive patients have increased risk of GI disease. 2
Screening for interstitial lung disease with pulmonary function testing and high-resolution CT when appropriate, especially in anti-topoisomerase 1 (Scl-70) positive patients. 3, 4
Critical Caveats
Avoid high-dose glucocorticoids (>10 mg daily) as they are themselves a risk factor for scleroderma renal crisis in patients with early dcSSc and TFRs. 3, 4
The presence of TFRs should trigger evaluation for other high-risk features including rapidly progressive skin involvement (increasing modified Rodnan skin score) and anti-RNA polymerase III antibodies. 3, 4
Treatment efficacy for TFRs is modest at best, emphasizing the importance of early detection and aggressive monitoring for organ complications rather than expecting complete resolution of the TFRs themselves. 1