Hydroxychloroquine Has No Role in Treating Scleroderma-Related Back Pain
Hydroxychloroquine is not recommended for systemic sclerosis (scleroderma) and provides no benefit for back pain in Scl-70 positive patients. The most recent EULAR guidelines for systemic sclerosis management do not include hydroxychloroquine as a treatment option for any manifestation of the disease 1.
Why Hydroxychloroquine Is Not Indicated
Lack of Evidence in Scleroderma
The 2025 EULAR recommendations for systemic sclerosis treatment cover 8 clinical domains (Raynaud's phenomenon, digital ulcers, pulmonary arterial hypertension, scleroderma renal crisis, skin fibrosis, interstitial lung disease, gastrointestinal manifestations, and arthritis) and do not recommend hydroxychloroquine for any of these manifestations 1.
For musculoskeletal involvement in scleroderma, mycophenolate mofetil is the first-line therapy, with methotrexate considered when musculoskeletal symptoms are predominant 2.
Scl-70 Antibody Significance
Scl-70 (anti-topoisomerase I) positivity indicates a higher risk for diffuse cutaneous involvement and interstitial lung disease, not a specific indication for hydroxychloroquine 3.
Scl-70 positive patients require thorough screening with pulmonary function testing and high-resolution CT of the lungs to detect interstitial lung disease 2.
Appropriate Management Approach
For Back Pain Evaluation
The back pain requires proper characterization: determine if it is inflammatory (morning stiffness >30 minutes, improvement with activity) versus mechanical 1.
If inflammatory back pain is present in a patient under age 45, consider screening for axial spondyloarthritis with HLA-B27 testing, as this is a separate condition from scleroderma 1.
For Scleroderma-Specific Treatment
Mycophenolate mofetil is first-line therapy for SSc-ILD and can address musculoskeletal symptoms 2.
Second-line options include tocilizumab, rituximab, and nintedanib, particularly for progressive fibrosing interstitial lung disease 2.
Avoid glucocorticoids in early diffuse cutaneous SSc due to increased risk of scleroderma renal crisis 2.
Critical Monitoring Requirements
Regular pulmonary function tests are essential in Scl-70 positive patients 2.
Blood pressure monitoring to detect scleroderma renal crisis 2.
Screening for cardiac, gastrointestinal, and other organ involvement 2.
Important Caveats
Hydroxychloroquine Risks
The FDA label warns of serious adverse effects including irreversible retinal toxicity, severe skin reactions (Stevens-Johnson syndrome, TEN), and neuropsychiatric reactions including suicidality 4.
These risks are unacceptable when the drug provides no established benefit for scleroderma 4.
Misdiagnosis Concerns
Back pain in a scleroderma patient may represent a separate coexisting condition (such as axial spondyloarthritis or mechanical back pain) rather than a scleroderma manifestation 1.
Proper evaluation with imaging (if inflammatory features present) and appropriate rheumatology consultation is warranted 1.