Digital Ulcers and Acute Digital Ischemia

Digital ischemia is the reduction in digital perfusion with impaired tissue viability and can frequently result in digital ulcers (DU). DU are denuded areas with a defined border, loss of epithelialization, and loss of epidermis and dermis. DU from digital ischemia typically occurs at the distal aspects of the digits. Because the management of digital ischemia varies depending on the etiology, it is important to be familiar with the differential diagnosis. Digital ischemia may manifest due to connective tissue diseases, vasculitis, diffuse arteriopathy, occupational diseases, paraneoplastic syndromes, steal phenomenon, radial artery cannulation, septic shock, and anatomic variants. Although DU usually heal on their own over time, non-pharmacologic and pharmacologic therapies show some efficacy in DU management. A variety of agents can serve as treatments such as those typically used for the management of Raynaud’s phenomenon (RP) and more novel vasodilators including endothelin-1 receptor antagonists, phosphodiesterase inhibitors, and prostanoids. However, if digital ischemia persists or progresses despite medical therapies, more aggressive management with procedures such as chemical and surgical sympathectomy, the local administration of botulinum toxin, vascular reconstruction, and/or amputation should be considered. In its more severe form, digital ischemia may present critically. This situation is a medical emergency and patients should be hospitalized and treated aggressively with medical and potentially surgical therapies to prevent digital loss. Novel therapeutic approaches such as single-port thoracoscopic sympathicotomy (SPTS), vascular reconstruction with bypass grafts, combined sympathectomy and vascular reconstruction, autologous fat grafting, and mesenchymal cell transplantation have shown promise in promoting DU healing and enhancing overall management of patients with digital ischemia and RP.