Figure.1 Early disease – Nodularity but without significant contraction of the fingers
This is slow-growing, inflammatory thickening on the palm of the hand that eventually creates a deformity starting in the ring and little fingers which, if not dealt with early, can spread across the whole hand. Although medical interventions may be required eventually, we describe here lifestyle and self-help strategies which may help delay progression and are a good option in the early stages of the condition.
Dupuytren’s contracture usually begins as a thickening of the skin on the palm of your hand. As Dupuytren’s contracture progresses, the skin on the palm of your hand may appear puckered or dimpled. A firm lump of tissue may form on the palm. This lump may be sensitive to the touch but usually isn’t painful.
Figure.2 More advanced disease causing considerable distortion and disability
In the later stages of Dupuytren’s contracture, cords of tissue form under the skin on your palm and may extend up to your fingers. As these cords tighten, your fingers may be pulled toward your palm, sometimes severely. Once this occurs, the fingers affected by Dupuytren’s contracture can’t be straightened completely, which can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands. Only rarely are the thumb and index finger affected. Dupuytren’s contracture can occur in both hands, though one hand is usually affected more severely than the other.
The deformity is caused by fibrosis and thickening around the tendon sheaths of the hand. The condition is known to be associated with:
Age – Dupuytren’s contracture typically occurs after the age of 50
Cancer treatments – Particularly long term hormone therapies such as aromatase inhibitors
Sex – Men are more likely to develop Dupuytren’s and to have more severe contractures than women
Ancestry – People of Northern European descent are at higher risk of the disease
Family history – Dupuytren’s contracture often runs in families
Tobacco smoking – Perhaps because of microscopic changes within blood vessels caused by smoking
Alcohol – High alcohol intake is associated with an increased risk, especially if cirrhosis develops
Other lifestyle factors – Lack of exercise, high saturated fat and low omega 3 and polyphenol intake
Diabetes – People with diabetes are reported to have an increased risk of Dupuytren’s contracture
Medication – Drugs including phenytoin and aromatase inhibitors are linked to the condition
This technique uses a needle, inserted through your skin, to puncture and “break” the cord of tissue that’s contracting a finger. Contractures often recur, but the procedure can be repeated. Some doctors now use ultrasound to guide the needle, reducing the chance of accidental injury to nerves or tendons
The main advantages of the needling technique are that there is no incision, it can be done on several fingers at the same time, and very little physical therapy is usually needed afterwards. The main disadvantage is that it cannot be used in some locations on the finger because of the risk of nerve damage.
The Food and Drug Administration has recently approved injections of an enzyme, collagenase clostridium histolyticum (Xiaflex), for the treatment of Dupuytren’s contracture. The enzyme in this drug softens and weakens the taut cord in your palm. The day after the injection, your doctor will manipulate your hand in an attempt to break the cord and straighten your fingers.
In many ways, this is similar to the needling technique, except that the manipulation happens the following day instead of during the injection procedure. The advantages and disadvantages of the enzyme injection are similar to needling, except that the enzyme injection may be more painful initially. Currently, enzyme injections can be used on only one joint at a time and treatments must be spaced at least a month apart.
Radiotherapy is a non-surgical treatment that can stop or slow down Dupuytren’s disease in its early stage. In radiation therapy, the nodules and cords associated with Dupuytren’s are irradiated from a distance of .5 – 1 cm, either with X-Rays (e.g. 120 kV = soft X-Rays that do not penetrate deeply into the body) or electrons (3 – 10 MeV). This is typically done over five days in a row ( total dose 15 Gy). After a break of six weeks, this treatment is repeated.
Another option is to surgically remove the tissue in your palm affected by the disease. This may be challenging because it’s difficult to identify affected tissue in the very early stages of the disease. Diseased tissue may also attach to the skin, making it difficult to remove and increasing the chances of recurrence.
The main advantage of surgery is that it results in a more complete joint release than that provided by the needle or enzyme methods. The main disadvantages are that physical therapy is usually needed after surgery, and the recovery time can be longer.
In some severe cases, surgeons remove all the tissue likely to be affected by Dupuytren’s contracture, including the attached skin. In these cases, a skin graft will be needed to cover the open wound. This surgery is the most invasive option and has the longest recovery time. People usually require months of intensive physical therapy afterwards.