Dupuytren Contracture Medication

  • Author: Stephanie Danielle Mathew, DO; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Dec 8, 2011
 

Medication Summary

In February 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (Xiaflex) for the treatment of Dupuytren contracture. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cords.[2, 76, 69, 70, 71]

Complications associated with collagenase C histolyticum are common; they include injection site reactions, peripheral edema, bruising, bleeding, and pain. More serious reactions include tendon rupture and complex regional pain syndrome. (To date, tendon rupture has been described in 0.3% of 1082 patients.)[2, 76]

Intermittent reports detail a decrease in the size of nodules with the use of corticosteroid injections. However, corticosteroids are associated with a high risk of complications, including fat atrophy and skin discoloration.[72] In addition, intralesional injection of corticosteroids can result in tendon rupture.

Because Dupuytren contracture is generally painless, analgesic medications usually are not required.

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Enzymes

Class Summary

Collagenase Chistolyticum was approved in February 2010 for percutaneous fasciotomy. Collagenase Chistolyticum is a protease that hydrolyzes collagen and breaks down its triple helix conformation, thus disrupting the Dupuytren cord. It is composed of 2 purified microbial collagenases and is indicated only for those patients with a palpable cord.

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Collagenase Clostridium histolyticum (Xiaflex)

 

This is a proteinase that hydrolyzes collagen in its native triple-helical conformation, resulting in lysis of collagen deposits. Injection into a Dupuytren cord (composed mostly of collagen) may result in enzymatic disruption of the cord. Injection is indicated for Dupuytren contracture with a palpable cord.

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Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.

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Triamcinolone (Kenalog-40, Aristospan)

 

Triamcinolone is used in the treatment of inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

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Contributor Information and Disclosures
Author

Stephanie Danielle Mathew, DO  Fellow, Department of Rheumatology, San Antonio Uniformed Services Health Education Consortium

Stephanie Danielle Mathew, DO is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel F Battafarano, DO, FACP, FACR  Clinical Professor of Medicine, University of Texas Health Science Center at San Antonio; Associate Professor of Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Chief of Rheumatology Service, San Antonio Military Medical Center

Daniel F Battafarano, DO, FACP, FACR is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

Additional Contributors

Milton B Armstrong, MD, FACS Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami Miller School of Medicine

Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, and National Medical Association

Disclosure: Nothing to disclose.

D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA) Associate Clinical Professor, Department of Plastic Surgery, University of California at San Diego; Private Practice, LaJolla, California

D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA) is a member of the following medical societies: American College of Surgeons, American Medical Assocation, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, California Society of Plastic Surgeons, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; Genentech Grant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting; Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rene Cailliet, MD Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

David W Chang, MD, FACS Associate Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Theresa Dressler Conologue, DO, FAAD Physician, Department of Dermatology, Geisinger Medical Center

Theresa Dressler Conologue, DO, FAAD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Evan R Farmer, MD Clinical Professor of Pathology and Dermatology, Department of Pathology, Virginia Commonwealth University School of Medicine

Evan R Farmer, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, and International Society of Dermatology

Disclosure: Nothing to disclose.

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology, and Society for Investigative Dermatology

Disclosure: Elselvier

Felisa S Lewis, MD Staff Physician, Department of Dermatology, Madigan Army Medical Center

Felisa S Lewis, MD, is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Carlos J Lozada, MD Director of Rheumatology Fellowship Program, Professor, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine

Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Pfizer Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joseph A Molnar, MD, PhD, FACS Director, Wound Care Center, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, Undersea and Hyperbaric Medical Society, and Wound Healing Society

Disclosure: KCI, Inc. Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Don R Revis Jr, MD Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine

Don R Revis Jr, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Frank R Rogers, MD, MBA Associate Professor, Division of Plastic and Reconstructive Surgery, Director, Undergraduate Education, Department of Surgery, Loma Linda University School of Medicine

Frank R Rogers, MD, MBA is a member of the following medical societies: American Association for Hand Surgery, American College of Physician Executives, American College of Surgeons, American Society of Plastic and Reconstructive Surgery, and Association for Surgical Education

Disclosure: Nothing to disclose.

Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society

Disclosure: Nothing to disclose.

Kristina Shaffer, MD, MPH Consulting Staff, Department of Dermatology, Dermatology Consultants

Kristina Shaffer, MD, MPH is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose

Dev Sinha, MD Research Associate/Physiatrist Observership, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Disclosure: Nothing to disclose.

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wendy Wing-Heen-Lo Wong, MD Research Fellow in Plastic and Reconstructive Surgery, Department of Plastic Surgery, Loma Linda University School of Medicine

Wendy Wing-Heen-Lo Wong, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston

Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the previous contributions of Debra Ibrahim, New York College of Osteopathic Medicine Class of 2008, Evish Kamrava, St. George's University School of Medicine Class of 2009, Jason Lee, St. George's University School of Medicine Class of 2010, Cyrus Kao, St. George's University School of Medicine Class of 2011, and Robert Mathew, to the development or revision of a source article.

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Arrow denotes the cord often present in Dupuytren contracture. Metacarpophalangeal joint and proximal interphalangeal joint contractures are also present.
Arrow denotes the typical cords of Dupuytren contracture. These cords are usually painless. Note the metacarpophalangeal joint contracture.
This photo demonstrates the presence of a nodule as well as skin blanching with extension of the affected digits.
Ultrasound of the palm in Dupuytren disease of the fourth digit; the Dupuytren nodule and thickening of the palmar fascia with puckering of the skin is noted. Green arrow: Flexor tendon; Red arrow: Dupuytren nodule; Blue arrow: Thickened palmar fascia; Yellow arrow: Puckering of the skin.
This photo shows a patient with an inability to extend the fourth and fifth digits. The differential diagnosis includes Dupuytren contracture, which is a flexion contracture most commonly involving digits 4 and/or 5.
Visible cord characteristic of Dupuytren disease with planned markings for surgical release.
Dissection of a diseased cord.
Normal anatomy of digital ligaments.
Three clinical grades of Dupuytren disease.
Parts of the palmar and digital fascia that become diseased in Dupuytren disease (left). Diseased fascia that is associated with the pretendinous cord (center). Diseased fascia that is not associated with the pretendinous cord (right).
Normal parts of the fascia that produce the spiral cord (left). The spiral cord demonstrating medial displacement of the neurovascular bundle in Dupuytren disease (right).
 
 
 
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