Systemic sclerosis (SSc), also called scleroderma, is a rare chronic autoimmune disease
that can have a wide range of cutaneous, joint, and internal organ involvement. In the
skin, SSc is characterized by enhanced fibroblast activity leading to hypertrophic dermal
collagen that results in thickened, less flexible skin. (Hassani, 2016) SSc is often
divided into two types based on extent of cutaneous involvement: diffuse SSc and limited
SSc. The hand is a frequent area of involvement in both subtypes of SSc. Hand disability
in SSc leads to a high burden on quality of life for patients as it limits both work and
activities of daily living. Treatment for hand sclerosis remains limited with generally
progressive disease despite aggressive treatment with anti-fibrotic medications,
immunosuppressive agents, and topical approaches. Specific hand therapies include
physiotherapy and injections of autologous adipose-derived stromal vascular fraction into
the fingers with some success. (Guillaume-Jugnot, 2016; Liem, 2019)
Ultraviolet therapy has been used in dermatology for several decades. UVA-1 is a form of
phototherapy that utilizes the longest wavelengths in the UV spectrum from 340-400 nm. It
is able to penetrate deeper in the skin than other types of phototherapy and target
different types of cells including fibroblasts. In sclerosing skin conditions UVA-1
appears to be superior to other forms of UV light. Medium to high dose UVA-1 also appears
to be superior to low dose UVA-1 for sclerosing conditions. (Kreuter 2006).
UVA-1 has been reported to be beneficial to skin changes in SSc in several case reports
and a few small studies. (Jacobe 2020) Interpretation of these reports has been difficult
based on the small numbers of subjects involved and the non-blinded non-randomized nature
of the reports. In a single controlled study with half-side comparison of 9 patients, the
investigators could not demonstrate improvement with UVA-1 in the treated hand. (Thomas
2007) This study was limited by a small number of patients and the long disease duration
prior to treatment (mean of 13 years). A more recent report of a patient with SSc for 2.5
years and severe acrosclerosis that responded to 21 sessions of UVA-1 with improved
mobility and functionality renews interest in this treatment modality. (Cuenca-Barrales
2019)
If UVA1 therapy can significantly improve hand involvement in SSc with regards to
functionality and disability, it may be a cost-effective and beneficial treatment for
this patient segment with debilitating disease.
Purpose and Objectives:
1. To assess the efficacy of 30 sessions of ultraviolet-1 (UVA1) therapy in treating
hand involvement of SSc in a prospective, randomized, investigator-blinded,
intra-patient, UV-blocking glove-controlled, crossover clinical trial.
1. To compare improvement in hand function as measured by the Hand Mobility in
Scleroderma (HAMIS) test, in the UVA1-treated hand compared to control hand
(gloved).
2. To compare the improvement in hand function as measured by the Cochin hand
functional disability scale (CHFDS) in the UVA1-treated hand compared to
control hand (gloved).
3. To compare the improvement in skin hardening based on durometer measurements in
the UVA1-treated hand compared to control hand (gloved).
4. To measure improvement in the physician measure of skin thickness on hands and
fingers (0-3) scale after completion of 30 UVA1 sessions.
5. To assess the duration of response after a complete 30-treatment course at 3
and12 months post treatment using the HAMIS, CHFDS, durometer, and physician
skin thickness assessment.
2. Assess patient-reported outcomes before, during and after treatment using
Skindex-16, Michigan Hand Questionnaire (MHQ), PROMIS-Physical Function (PROMIS-PF),
Hand Disability in Systemic Sclerosis
- - Digital Ulcers(HDISS-DU) and Visual Analog
Scale (VAS).
Study Design:
This study will use a single-blind, prospective, randomized (dominant/non-dominant hand)
comparator design to assess the effect of high dose (80-120 J/cm2) UVA1 therapy on hand
function in scleroderma in a paired t-test design. This study will be placebo-controlled
(with a UV-blocking gloved hand), cross-over, randomized clinical trial. Following the
initial treatment period (30 treatments), patients will have the option to undergo the
same high dose UVA1 treatment protocol on the untreated control hand. A follow up period
of 12 months following completion of UVA1 therapy will prospectively follow patients to
monitor for relapse of their disease to assess the durability of the clinical response to
UVA1 therapy on hand scleroderma.
Inclusion criteria:
- - Must be able to understand and provide written informed consent.
- - Scleroderma skin involvement affecting both hands approximately equally.
- - Age of at least 18-years-old.
- - Ability to engage in twice weekly UVA1 sessions.
- - No changes in systemic therapy during the first 100 days of the study period.
Exclusion criteria:
- - On photosensitizing medication.
- - Inability to complete study visits.
- - UV light therapy in the 4 weeks prior to entering the study.
- - Commercial tanning or excessive sun exposure in the 4 weeks prior to entering the
study.
- - Current pregnancy or planned pregnancy during the study period.
- - Use of topical therapies other than emollients (suprapotent corticosteroids) in the
2 weeks prior to entering the study.
- - History of intolerance to ultraviolet light.
- - Any other condition that will disqualify the patient from the study in the opinion
of the investigator.
Procedures:
This is a single-blinded, randomized, UV-blocking glove controlled, dominant/non-dominant
hand, cross-over study to determine the efficacy of UVA1 in the treatment of hand
scleroderma. Each participant will have at least one hand treated with UVA1 during the
active treatment period of the study. The study will be performed at the University of
Utah Dermatology Department using both the University of Utah E12 Clinic space as well as
the Midvalley Clinic space. UVA1 lights boxes are located at both E12 and Midvalley
locations. Personnel involved in the study will include the PI, the co-investigators, and
the study coordinators. Approximately 27 patients will be enrolled to account for a 25%
drop-out rate. The number needed to treat to show a difference in the treatment vs.#46;
control hands is 21. The study timeline is summarized in Table 1.
Screening:
For screening, subjects with qualifying scleroderma involving both hands will be asked to
read and sign the informed consent document. They will be reminded that they are to take
their time and, if necessary, take it home for further consideration. Questions will be
answered. Those meeting inclusion / exclusion criteria who have signed informed consent
will be enrolled.
After answering questions and prior to the first treatment the Principal Investigator
(PI) will examine the entire patient and assess for the diagnosis of systemic sclerosis
with bilateral hand involvement and perform the following assessments: HAMIS, CHFDS,
durometer measurements, and mRSS. (Please see efficacy assessment section for details of
HAMIS, CHFDS, durometer, and mRSS). Photographs of the hands and other affected areas
will be taken. The patient will be asked to identify their dominant (writing) hand and
their answer will be noted. Using a random number generator, the patient will be
randomized to undergo UVA1 treatment vs.#46;UV-blocking glove (control) on the dominant hand.
The non-dominant hand will receive the other modality. A study coordinator will perform
the randomization on the day of first treatment and the PI will be blinded to the
treatment assignment.
UVA1 Treatments:
Blinding:
A UV-blocking glove will be placed on the control hand as determined by the randomization
process. Subjects will wear eyewear that occludes external light.
Evaluations for adverse effects will be carried out by the UVA1 operator (a nurse not
involved in any assessments) and the blinded investigator at prescribed intervals.
Evaluation of UVA1 efficacy on hand scleroderma will be assessed by a trained and
experienced evaluator who is blinded as to the UVA1-treated side (covered / not covered).
The efficacy evaluations will be carried out prior to treatments on days both evaluations
and treatments are completed. After participants have been evaluated at the 3-month
post-treatment study visit the blinded evaluator will become unblinded to the
UVA1-treated side for the purpose of allowing participants to receive standard of care
therapy. Therefore, participants will be allowed to receive additional UVA-1 treatments
to one or both hands in addition to any other necessary standard of care treatments after
the 3-month post-treatment visit.
Dosing Schedule:
Prior studies with UVA1 have shown that high and medium dose protocols (>40-120 J/cm2)
are more effective than low dose (20-40 J/cm2) to treat sclerosing skin conditions.
(Hassani, 2016) Thus, we will set the initiation dose at 50 J. The hands will be
positioned approximately 9 inches from the bulbs. The palmar surface of the hand will be
exposed for half the treatment and the dorsal surface for half the treatment. If
tolerating well after three treatments, the dose will be increased to 60 J for three
treatments and then 70 J for the remaining treatments.
Patients will return to clinic two-to-three times per week for 30 treatments over a
100-day period to receive UVA1 treatments. If the patient experiences redness, burning,
pain, or blistering at the treatment site, treatment will be held if active symptoms
persist at the time of the next scheduled treatment. If the symptoms have resolved and
the patient has healed by the next scheduled treatment, the UVA1 energy will be reduced
by 10 J of the previously delivered dose. Dose escalation will then proceed by increasing
the UVA1 energy after three well tolerated treatments.
Evaluations:
1. Efficacy evaluations will be performed at baseline, after 15 UVA1 treatment
sessions, after 30 UVA1 treatment sessions, and at 3 and 12 months after completion
of all UVA1 treatments. For each evaluation prior to the 12-month evaluation, one of
the sub-Investigators who is blinded to the treatment assignments will generate and
record the HAMIS, CHFDS, Durometer, and mRSS. Hands will be photographed. Patients
will complete all PROM including using Skindex-16, Michigan Hand Questionnaire
(MHQ), PROMIS-Physical Function (PROMIS-PF), Hand Disability in Systemic Sclerosis
- -
Digital Ulcers(HDISS-DU), and Visual Analog Scale (VAS).
The blinded evaluator will also perform safety evaluation and document study-related
adverse events.
1. Primary Efficacy Measure:
The efficacy will be measured using the HAMIS test score to assess for improvement
over time and as compared to the untreated hand. The primary endpoint will be
assessed after 30 UVA1 treatments. The primary endpoint is improvement in HAMIS
score as compared to the untreated hand after 30 UVA1 treatment sessions.
2. Secondary Efficacy Measures:
Secondary efficacy measures include HAMIS test score improvement from baseline in treated
and untreated hands after 30 UVA1 treatment sessions, as well as changes in CHFDS,
Durometer measures, mRSS, Skindex-16, MHQ, PROMIS-PF, and VAS scores between baseline and
after 30 UVA1 treatment sessions and (when applicable) between treated and untreated
hands. Other secondary efficacy measures include change in HAMIS test scores CHFDS,
Durometer measures, Physician assessment, Skindex-16, MHQ, PROMIS-PF, HDISS-DU, and VAS
scores between completion of 30 UVA1 treatments and 3 and 12 months post-treatment in
both hands as compared to baseline and after 30 UVA1 treatment sessions in each hand.
Secondary endpoint measures also include time to disease worsening after treatment as
defined by a 3-point (~10%) increase in HAMIS scores post-treatment.
Endpoint measure descriptions:
HAMIS is a hand function test developed for adults with systemic sclerosis. HAMIS
consists of 9 items designed to measure all movements assessed in an ordinary range of
motion (ROM)-measured hand test. Specific items test finger flexion and extension, thumb
abduction, pincer grip, finger abduction/swelling, dorsal extension and volar extension
of the wrist, and pronation and supination. Each item is graded on a 0-3 scale, where 0
corresponds to normal function and 3 denotes that the individual is unable to perform the
item. Each hand is assessed separately. The minimum score for HAMIS is 0, representing
normal hand function. The maximum score of HAMIS is 27, representing a high degree of
dysfunction. (Sandqvist, 2000)
The CHFDS is a questionnaire with 18 questions concerning daily living activities,
administered by a clinician, which each question scored on a scale from 0 (performed
without difficulty) to 5 (impossible to do). The total score is obtained by adding the
scores from all items (range 0-90), with lower scores indicating normal function and
higher scores indicating poor function. This test was developed for rheumatoid arthritis
but has been validated in scleroderma. (Rannaou, 2007)
A Durometer is an instrument for testing the hardness of various materials. It has been
used in scleroderma to measure the hardness of affected skin as compared to normal skin.
The physician assessment on skin thickness on the hand and fingers based on the modified
Rodnan skin score (mRSS) which is a standard outcome measure for skin disease in systemic
sclerosis. The score is calculated by evaluating the skin thickness at 17 different body
sites. Each site is graded from 0 to 3, with 0 representing normal skin and 3
representing severe skin thickness. The score is calculated by adding the scores at each
site to arrive at a total score ranging from 0 (normal) to 51 (severe disease). (Khanna,
2017) In this study we will only calculate the score for the hands and fingers. Total
possible score of 6 on each hand.
Skindex-16 is a 16-item validated assessment for the patient to identify the impact of
their skin disease on three quality of life domains: symptoms, emotions, and physical
functioning. Scores are normalized to a 0-100 scale with 0 representing no impact on
quality of life and 100 representing maximal impact.
The Michigan Hand Questionnaire (MHQ) is a 37-item validated instrument exploring
hand-specific outcomes across six domains: overall hand function, activities of daily
living (ADLs), pain, work performance, aesthetics, and patient satisfaction with hand
function. It asks questions separately about each hand, allowing for comparisons between
hands. The raw score is converted to a 0-100 scale. For pain, a higher score indicates
more pain, but for the other five scales, higher scores indicate better hand performance.
The score for the affected hand is obtained by selecting either the right or the left
hand score.
Hand Disability in Systemic Sclerosis
- - Digital Ulcers(HDISS-DU) is a patient reported
outcome measure developed to capture the full spectrum of symptoms and disability related
to digital ulcers, which are common and debilitating in scleroderma involving the hands.
The instrument consists of 24 items. Responses are scored from 1 to 6 (6 scores), where 1
is 'yes, without difficulty', 2 is 'yes, with a little difficulty', 3 is 'yes, with some
difficulty', 4 is 'yes with much difficulty', 5 is 'nearly impossible to do' and 'used
unaffected hand only' (both responses were assigned the same score), and 6 is
'impossible'. The eighth response option 'did not do this activity in the past 7 days' is
scored as missing. The overall HDISSDU score is calculated as the mean of non-missing
item scores (with a missing data threshold of < 12 items) and ranged from a minimum score
of 1 to a maximum score of 6, with increasing score corresponding to increasing
disability.
PROMIS Physical Function (PROMIS-PF) is a computer adaptive test (CAT), wherein initial
screening questions guide the need for additional questions following an iterative
algorithm. For example, if a patient is unable to walk 100 feet without resting, an
additional question about jogging 1 mile would not be asked. A weighted t-score results
based on national averages with 50 as the mean score; >50 means higher physical function,
<50 means lower physical function.
All PROs (Skindex-16, MHQ, PROMIS-PF) will be collected electronically at every visit.
