Systemic Sclerosis: Initial Evaluation, First-Line Therapy, and Follow-Up
For systemic sclerosis, begin with mycophenolate mofetil as first-line therapy for early diffuse cutaneous disease with progressive skin or lung involvement, while implementing organ-specific screening and treatment algorithms based on the 2025 EULAR guidelines. 1
Initial Evaluation
Essential Baseline Assessment
Classify disease subtype immediately: Determine if the patient has limited cutaneous SSc (skin involvement distal to elbows/knees only) versus diffuse cutaneous SSc (proximal and/or truncal involvement), as this drives treatment intensity and prognosis 1, 2.
Measure modified Rodnan skin score (mRSS): Assess skin thickness at 17 anatomical sites on a 0-3 scale (total range 0-51) to quantify disease severity and identify high-risk patients requiring aggressive therapy 2, 3.
Obtain autoantibody profile: Test for anti-topoisomerase I (Scl-70), anti-centromere, and anti-RNA polymerase III antibodies, as these predict organ involvement patterns and disease trajectory 2, 3.
Mandatory Organ Screening
- Pulmonary evaluation: Perform baseline pulmonary function tests (PFTs) with DLCO and high-resolution chest CT to detect interstitial lung disease (ILD), which occurs in 40-75% of patients 2, 3
- Cardiac assessment: Obtain echocardiography to screen for pulmonary arterial hypertension (PAH) and evaluate for scleroderma-related cardiac disease 4, 3
- Renal monitoring: Establish baseline blood pressure and creatinine, as scleroderma renal crisis is life-threatening and requires urgent detection 4, 3
- Gastrointestinal screening: Assess for dysphagia, reflux, and motility disorders, which affect nearly 90% of patients 1, 2
First-Line Therapy Algorithm
For Early Diffuse Cutaneous SSc with Progressive Disease
Mycophenolate mofetil is the preferred initial agent for patients with progressive skin thickening and/or ILD, having surpassed cyclophosphamide as first-line therapy 1, 3.
Alternative first-line options based on disease features:
- Methotrexate: Consider for less severe skin involvement and concomitant inflammatory arthritis 3, 5
- Rituximab: Use for severe and refractory systemic manifestations or when mycophenolate fails 1, 3
- Tocilizumab: Emerging option for skin fibrosis and ILD based on recent trial data 1
For Rapidly Progressive Early Diffuse Cutaneous SSc
Autologous hematopoietic stem cell transplantation (HSCT) should be considered for high-risk patients with very high mRSS or moderate skin involvement with worsening ILD, as it can improve survival 1.
For SSc-Interstitial Lung Disease
Start mycophenolate mofetil as initial therapy for SSc-ILD 1, 3.
Add nintedanib if ILD is fibrotic and progressing despite immunosuppression; pirfenidone is a possible alternative 1, 3.
For Pulmonary Arterial Hypertension
Initiate combination therapy immediately with phosphodiesterase-5 inhibitor (e.g., sildenafil) plus endothelin receptor antagonist (e.g., bosentan or ambrisentan) for newly diagnosed PAH 1, 3.
Add prostacyclin analogue if inadequate response to initial combination therapy 1, 3.
For Raynaud Phenomenon and Digital Ulcers
First-line: Dihydropyridine calcium channel blockers, especially nifedipine 1.
Second-line: Phosphodiesterase-5 inhibitors or intravenous iloprost if calcium channel blockers are insufficient 1.
For digital ulcer prevention: Bosentan reduces development of new digital ulcers 1.
For Scleroderma Renal Crisis
Initiate ACE inhibitor therapy immediately upon detection of blood pressure elevation or renal dysfunction 3.
Avoid high-dose corticosteroids in early diffuse cutaneous SSc, as they increase scleroderma renal crisis risk 4, 3.
Follow-Up Strategy
Monitoring Frequency and Parameters
Annual screening is mandatory:
- Pulmonary function tests with DLCO to detect progressive ILD 3
- Echocardiography to screen for PAH development 3
- Modified Rodnan skin score to track disease activity 2, 3
Frequent blood pressure monitoring (at least monthly) to detect early scleroderma renal crisis 4, 3.
Regular disease activity assessment with therapeutic adjustment based on organ involvement progression 3.
Multidisciplinary Coordination
Rheumatology must lead the treatment approach with mandatory coordination across specialties 4, 3:
- Pulmonology for ILD management
- Cardiology for PAH and cardiac involvement
- Nephrology for renal crisis
- Gastroenterology for GI manifestations
- Physical and occupational therapy for functional impairment 4, 3
Critical Pitfalls to Avoid
Do not use high-dose corticosteroids in early diffuse cutaneous SSc due to increased scleroderma renal crisis risk 4, 3.
Do not delay immunosuppression in progressive disease, as early treatment with disease-modifying agents improves outcomes 1.
Do not miss anti-topoisomerase I antibodies, as these patients require urgent pulmonology evaluation due to higher ILD frequency 4.
Do not rely on skin findings alone to guide therapy—visceral involvement drives prognosis and mortality 1, 2.