Scleroderma affects the hands in a number of different ways. Skin changes in sclero- derma can have an especially devastating impact. Although the course of scleroderma is variable and not all people experience every phase, the changes to the hand often evolve in three phases. In the earliest phase, swelling of the fingers and hands predomi- nates, especially in individuals with diffuse scleroderma. Swelling may be associated with or even precede the onset of Raynaud's phenomenon. This swelling tends to limit the movement of the finger and hands. Dur- ing the next phase, the swollen areas transform into hardened plaques and the skin thickens. This is when the most promi- nent loss of functionality often occurs. These changes, combined with the loss of wrist mobility, can lead to the hand becom- ing stuck in a “claw-like” position. In the last phase, called the atrophic phase, the skin becomes thinner and more fragile, and the claw-like deformations increase. Wrist movements can become very limited at this point.

Swelling

Many people experience swelling early in the course of scleroderma. This swelling may last weeks or years, and sometimes improves on its own. For some patients it may progress to more severe skin involve- ment, such as thickening or contractures. Swelling of the hands tends to affect the fin- gers, knuckles, and back of the hand. This can be problematic for performing daily tasks: for example, having puffy, thickened fingers may make it difficult or even impos- sible to close the hands into a fist. The swelling is generally worse in the morning because the muscles are inactive for a long time overnight, then lessens throughout the day as you start moving your hands more. What you can do: Ask your physician to recommend medica- tions to alleviate the swelling. It is worthwhile to note that water pills or di- uretics that are sometimes used to treat swelling generally do not work in sclero- derma, as the problem is not caused by water retention. Practicing simple exercises i may also help to prevent swelling from reducing your range of motion.

Sclerodactyly and Contractures

One of the most typical symptoms of sclero- derma, sclerodactyly refers to shiny tightness of the skin that often occurs after the initial phase of swelling has subsided. Sclerodactyly can affect functioning by making it difficult to straighten the fingers from a curled position. This tightening and thickening sometimes spreads to the arms, legs, trunk, neck, and face, usually peaking around 3-4 years after its onset; with time, it may improve on its own. Sclerodactyly is caused by an over-production of collagen, a major component of the connective tissue that makes up our bodies. This build-up of collagen causes the skin to thicken, and de- stroys sweat and oil glands, leading to dry and hard skin. In more severe cases, the tightening of the skin and the underlying tissues (including tendons) can cause the fingers to become fixed in one position. We call this a contrac- ture. Contractures limit the ability to both flex and extend the fingers. Contractures can cause problems in two ways. First, the decreased range of movement can make it hard to use the fingers for everyday tasks. Second, it becomes easier to sustain injuries to the knuckles when one’s fingers are bent, as the knuckles stick out and can hit against things easily. What you can do: Perform daily hand exercises to stretch your joints. Keep skin moisturized and protected. Take care to avoid skin trauma like bruises, scrapes, and cuts, which might occur when doing activities like household chores, sports, or lifting heavy objects.