Understanding Dupuytren's Contracture
Before exploring the specific medications, it is essential to understand the condition they are meant to treat. Dupuytren's contracture is a progressive hand deformity caused by an inherited fibroproliferative disorder that leads to an abnormal thickening of the fascia, the tissue just beneath the skin of the palm. Over time, this thickened tissue forms tough, rope-like cords that pull one or more fingers toward the palm, making it difficult or impossible to fully straighten them. The condition most commonly affects the ring and pinky fingers, but it can impact any finger and is more prevalent in men over 40, especially those of Northern European descent. While generally painless, the contracture can significantly impair hand function and daily activities.
The Primary Medication: Collagenase Clostridium Histolyticum (Xiaflex)
For decades, surgical intervention was the primary treatment for advanced Dupuytren's contracture. However, the FDA approved collagenase clostridium histolyticum, sold under the brand name Xiaflex, in 2010 as a non-surgical, injectable treatment for adults with a palpable cord.
How Xiaflex Works
Xiaflex is a biologic injectable derived from the bacterium Clostridium histolyticum. The medication contains two purified microbial collagenases that act as proteinases, meaning they break down proteins. When injected directly into a Dupuytren's cord, these enzymes target and dissolve the excess collagen that forms the thickened cord. This enzymatic disruption weakens the cord, preparing it for the next step of the procedure.
The Xiaflex Treatment Procedure
Treatment with Xiaflex is an outpatient procedure performed by a hand specialist trained in the injection technique.
- Day 1 (Injection): The specialist injects Xiaflex directly into the collagen cord in the hand. The hand is then bandaged, and the patient is advised to avoid strenuous activity and to keep the hand elevated to minimize swelling.
- Day 2-3 (Manipulation): The patient returns to the clinic for a follow-up appointment. The doctor administers a local anesthetic before manipulating the finger to manually extend and break the weakened cord. This process helps straighten the finger and restore function. The patient may then be instructed on exercises and splinting to maintain the achieved range of motion.
- Follow-up Injections: If a contracture persists after the initial treatment, the process can be repeated up to three times per cord at approximately 4-week intervals. Up to two cords can be injected in one hand during a single visit.
Corticosteroid Injections for Early-Stage Nodules
In the early stages of Dupuytren's disease, patients may experience painful or rapidly growing nodules in the palm before a significant contracture develops. For these specific symptoms, a hand specialist may consider corticosteroid injections. Corticosteroids like triamcinolone are powerful anti-inflammatory medications that can be injected directly into the nodules to provide relief and potentially slow the progression of the disease.
It is important to note, however, that corticosteroid injections are generally not effective for treating existing cord formations or established contractures. Furthermore, they carry risks such as fat atrophy, skin discoloration, and, though rare, potential tendon rupture. For these reasons, their use is limited and decided on a case-by-case basis.
Comparison of Hand Contracture Treatment Options
Selecting the right treatment depends on the severity of the contracture, the patient's overall health, and the location of the affected joints. Here is a comparison of the primary medical and procedural options:
Feature | Collagenase Injection (Xiaflex) | Corticosteroid Injections | Needle Aponeurotomy | Limited Fasciectomy (Surgery) |
---|---|---|---|---|
Mechanism | Injected enzyme dissolves collagen cord. | Anti-inflammatory medication reduces painful nodule symptoms. | Percutaneous needle divides collagen cord. | Surgical removal of thickened fascia. |
Ideal for | Palpable cords causing contracture in MCP and PIP joints. | Painful, early-stage nodules without significant contracture. | Contractures primarily at the MCP joint. | Advanced, complex disease, or recurrent contractures. |
Procedure | Minimally invasive, in-office injection followed by manipulation. | Minimally invasive, in-office injection(s). | Minimally invasive, in-office procedure using a needle. | Invasive, operating room procedure. |
Recovery | Faster recovery, typically days to weeks. | Minimal downtime, but limited effectiveness on contracture. | Fast recovery, similar to Xiaflex. | Longest recovery, requiring hand therapy and splinting for months. |
Recurrence Rate | Higher than surgery (~30% at 3 years), but retreatable. | High recurrence if used on nodules, ineffective for cords. | Relatively high recurrence rate compared to surgery. | Lower initial recurrence rate than less invasive options. |
Main Risks | Tendon or ligament damage, bruising, swelling, allergic reaction. | Fat atrophy, skin discoloration, rare tendon rupture. | Nerve or tendon damage, skin tears. | Nerve damage, infection, poor wound healing, stiffness. |
The Decision-Making Process
When considering treatment for a hand contracture, several factors are evaluated by a hand specialist, including the severity of the contracture, the affected joints, and the patient's personal preferences. For instance, while both Xiaflex and needle aponeurotomy are less invasive than surgery, studies have shown that surgery may provide better long-term outcomes for proximal interphalangeal (PIP) joint contractures. Conversely, for metacarpophalangeal (MCP) joint contractures, Xiaflex and needle aponeurotomy may be comparable to surgery in the short term, with faster recovery times.
For mild cases without functional impairment, a doctor might recommend a period of observation. For painful nodules, corticosteroids might be considered cautiously. For a palpable cord causing functional limitations, Xiaflex offers an effective, minimally invasive alternative to surgery, though recurrence is common. A full and transparent discussion with a specialist about the risks and benefits of each option is crucial for deciding on the best course of action.
Conclusion
While a variety of treatments exist for hand contracture, primarily caused by Dupuytren's disease, the most prominent medication available is collagenase clostridium histolyticum, marketed as Xiaflex. This injectable enzyme provides a valuable non-surgical option for many patients by breaking down the fibrous cords that cause the fingers to curl. Other medications, like corticosteroid injections, are limited to treating specific symptoms in the earliest stages. The most effective treatment plan is highly individualized and requires consultation with a hand specialist to weigh the benefits and risks of medical, procedural, and surgical options.
Learn more about Dupuytren's Contracture from the American Academy of Orthopaedic Surgeons.