How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?

Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most commonly) or calcinosis (also typically at fingertips). If the ulcers really seem to be due to Raynaud/ischemia and are progressing or non-healing, then I would consider IV epoprostenol in patients who...

My experience in the referral to hand surgery is much like Dr. @Dr. First Last; it is really important to ensure the surgeon offers sympathectomy and not “limited amputation” of the distal digit. This never treats the issue.

I do use calcium channel blockers, PDE5 inhibitors, SSRIs (fluoxetine), and anticoagulation before going for other interventions, though.

It is always important to remember that when a rheumatologic disorder is not behaving as we would anticipate, it is reasonable to look fo...