Clinical bottom line
Refractory palmar fasciitis and Dupuytren’s contracture (DC) remain challenging complications in patients with rheumatic diseases, often leading to progressive hand deformity and functional impairment. Current management primarily involves surgical interventions, but emerging novel therapies targeting the fibrotic and vascular remodeling processes underlying DC show promise. However, robust clinical trial data on these novel treatments in rheumatic populations are limited. Clinicians should consider a multidisciplinary approach integrating established surgical techniques with cautious exploration of emerging pharmacotherapies, while recognizing the need for further evidence to guide practice.
What the evidence shows
Dupuytren’s contracture is characterized by progressive fibrosis of the palmar fascia, leading to flexion contractures of the fingers and impaired hand function (Fassbender et al., 2002). Histopathologically, the disease involves myofibroblast proliferation and excessive collagen deposition, with a complex interplay of genetic, environmental, and microvascular factors (Brinster et al., 2011). Notably, arterial remodeling and altered microhemodynamics in the palmar fascia have been implicated in DC pathogenesis, suggesting a vascular component to the fibrotic process (Shchudlo et al., 2018).
Traditional management of refractory DC in rheumatic patients relies heavily on surgical fasciectomy, which can provide functional improvement but carries risks of recurrence and complications (Douglass et al., 2016; Duncan et al., 2015). In severe or recurrent cases, arthrodesis or even amputation may be considered, though these are last-resort options due to their impact on hand function and quality of life (Izadpanah et al., 2016a; Izadpanah et al., 2016b).
Emerging therapies under investigation include collagenase clostridium histolyticum injections, anti-fibrotic agents, and vascular-targeted treatments aiming to modulate the underlying pathological processes. While these approaches have shown efficacy in non-rheumatic DC populations, data specific to patients with rheumatic diseases remain sparse. Additionally, palmar fasciitis can also present as a paraneoplastic syndrome associated with malignancies such as tubal carcinoma, complicating diagnosis and management (Denschlag et al., 2004).
Caveats and uncertainty
The majority of evidence on DC management derives from studies in the general population rather than rheumatic cohorts, limiting direct applicability. Rheumatic disease–associated palmar fasciitis may have distinct pathophysiological mechanisms, including autoimmune-mediated inflammation, which are not fully elucidated. Furthermore, the natural history of DC in rheumatic patients and response to novel therapies may differ due to concomitant immunosuppressive treatments.
Surgical interventions, while effective, carry risks of neurovascular injury, infection, and recurrence, necessitating careful patient selection and expertise. The long-term safety and efficacy of emerging pharmacotherapies in rheumatic populations remain unproven, and their integration into treatment algorithms requires validation through controlled trials.
Finally, the potential overlap between paraneoplastic palmar fasciitis and rheumatic disease manifestations underscores the importance of thorough evaluation to exclude malignancy in atypical or refractory cases.
How this may change practice
Clinicians managing refractory palmar fasciitis and DC in rheumatic disease patients should maintain a high index of suspicion for disease progression and complications, employing regular functional assessments and imaging as appropriate. Surgical fasciectomy remains the cornerstone for advanced contractures, but emerging therapies targeting fibrosis and vascular remodeling warrant consideration in selected cases, ideally within clinical trial settings.
Multidisciplinary collaboration involving rheumatologists, hand surgeons, and rehabilitation specialists is essential to optimize outcomes. Awareness of paraneoplastic palmar fasciitis should prompt appropriate oncologic evaluation in refractory or atypical presentations.
Future incorporation of novel anti-fibrotic and vascular-targeted agents may offer less invasive alternatives or adjuncts to surgery, potentially improving functional outcomes and reducing recurrence. However, clinicians should exercise caution pending further evidence and tailor treatment plans to individual patient profiles.