Radiotherapy for Dupuytren's

Radiation treatment for Dupuytren's disease has been performed since the advent of therapeutic radiation treatment. The effectiveness of radiation is reported as a preventative measure for early disease to prevent progression, not as a treatment for contracture. Although not widely embraced in the United States, there is a large European experience with radiotherapy of Dupuytren's Disease. Literature access is restricted by the unfortunate fact that reports have been published in journals whose publishers continue to lag behind the trend to provide open internet access access to their publications. Medline abstracts are available and a Medline search this month of Radiotherapy for Dupuytren's is available here (full text: http://www.dupuytrenfoundation.org/DupPDFs/2010_Medline_XRT.pdf). These articles report a benefit of radiotherapy in early stage Dupuytren's in slowing the progress of contracture, a low complication rate, no reports of radiation induced cancer and no interference with later surgery for those who failed radiation and developed progressive contractures. These reports must be reviewed with the knowledge of anecdotal reports in surgical texts of significant complications from radiation for Dupuytren's. The truth lies somewhere in between. The difficulty with interpreting reports of any treatment of Dupuytren's is lack of information regarding additional risk factors: The biologic aggressiveness of Dupuytren's, progression and recurrence, is predictably and significantly affected by family history, presence of knuckle pads, Ledderhose, Peyronie's or frozen shoulder, age, age of onset, bilaterality and number of digits involved, nodularity of disease, skin involvement, certain medications, alcohol intake and other risk factors. The true effectiveness of any preventative treatment must take these types of factors into account to have real validity. This is why a standard approach to documentation and a global collaborative effort to generate and analyze large amounts of data is important to make progress in developing better treatment options for Dupuytren's and related conditions.

Dupuytren's: it's not just the fascia.

Dupuytren's contracture is a local manifestation of a systemic process, and although the palmar fascia is the usual focus, what happens in the hand is a regional process, affecting the skin and the fatty layer under the skin as well as the fascia: it appears to be something which brews between the skin and the fascia, not just in the fascia. This concept and its consequences were eloquently reviewed by the late, great John Hueston in "The role of the skin in Dupuytren's disease" (full text: http://www.dupuytrenfoundation.org/DupPDFs/1985_Hueston_1125.pdf). His observations regarding the anatomy ("A nodule is never found on the dorsal aspect of a palmar aponeurosis..."), the biology ("...obsession with the collagenous structure of the palmar tissues is at present being replaced by the more logical study of the cellular origins..."), and the logic of dermofasciectomy and full thickness skin graft for aggressive or recurrent Dupuytren's are even more relevant today than when the article was published 25 years ago.

Alcohol and Dupuytren's

Is there a relationship between drinking alcoholic beverages and the chance of having Dupuytren's? This has been debated for years. The answer? Yes, according to the report "Dupuytren's contracture and alcohol" (full text: http://www.dupuytrenfoundation.org/DupPDFs/1986_Bradlow_1148.pdf). The authors reviewed 143 patients with and without Dupuytren's, checked their self described drinking patterns as well as the blood tests which are abnormal in heavy drinkers, and concluded that, at least in men, regular heavy alcohol consumption, measured either by history or blood tests, was associated with a higher risk of Dupuytren's contracture. Why? There are many possible biological reasons, including the chemical effects of alcohol (or its byproducts) and the effect of alcoholic liver disease on the metabolism. On the bright side, light or moderate alcohol consumption - meaning not enough to show liver damage - is apparently not a risk factor for the development of Dupuytren's disease. Whew.

Dupuytren's Diathesis

What is Dupuytren's Diathesis? Diathesis is a medical term meaning tendency toward a condition. One way of describing a person with Dupuytren's diathesis is that they have more of whatever Dupuytren's is. Diathesis usually means more aggressive Dupuytren's: earlier age of onset; more fingers involved; more often bilateral; faster progression; more recurrence problems. The hallmark is developing more than one member of the Dupuytren family: Dupuytren's; knuckle pads; Ledderhose; Peyronie's; frozen shoulder. More conditions means more aggressive biology. People with Dupuytren's diathesis are more likely to have ancestors with Dupuytren's and are more likely to pass Dupuytren's on to their children than people with only Dupuytren's. In this article, "Dupuytren's Diathesis: A Case Report" (full text: http://www.dupuytrenfoundation.org/DupPDFs/1964_Lettin.pdf), the difficulties experienced by a patient with Dupuytren's diathesis are described, as well as complcations from both surgery and radiation treatment. Diathesis is a persistent reminder that Dupuytren's is a systemic disorder which has many forms, and that we need to continue work to find a biological cure.