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review article
Mechanisms of Disease
Scleroderma
Armando Gabrielli, M.D., Enrico V. Avvedimento, M.D., and Thomas Krieg, M.D.
S
cleroderma (systemic sclerosis) is a complex disease in which ex- From the Department of Medical Science
tensive fibrosis, vascular alterations, and autoantibodies against various cellular and Surgery, Section of Clinical Medicine,
Università Politecnica delle Marche, and
antigens are among the principal features (Fig. 1 and 2).1 There are two major Ospedali Riuniti — both in Ancona (A.G.);
subgroups in the commonly accepted classification of scleroderma: limited cutane- and the Department of Molecular and
ous scleroderma and diffuse cutaneous scleroderma.2 In limited cutaneous sclero- Cellular Biology and Pathology, Institute of
Endocrinology and Experimental Oncol-
derma, fibrosis is mainly restricted to the hands, arms, and face. Raynaud’s phenom- ogy, Consiglio Nazionale delle Ricerche,
enon is present for several years before fibrosis appears, pulmonary hypertension University of Naples Federico II, Naples
is frequent, and anticentromere antibodies occur in 50 to 90% of patients. Diffuse (E.V.A.) — all in Italy; and the Depart-
ment of Dermatology, University of Co-
cutaneous scleroderma is a rapidly progressing disorder that affects a large area of logne, Cologne, Germany (T.K.). Address
the skin and compromises one or more internal organs. reprint requests to Dr. Gabrielli at the De-
We believe that the acronym CREST (calcinosis, Raynaud’s phenomenon, esopha- partment of Medical Science and Surgery,
Section of Clinical Medicine, Polo Didat-
geal motility dysfunction, sclerodactyly, and telangiectasia) is obsolete, since it can- tico, Via Tronto, 10, Ancona, Italy, or at
not be assigned to only one subgroup of patients with the disease and does not a.gabrielli@univpm.it.
sufficiently indicate the burden of internal-organ involvement. In rare cases, patients
N Engl J Med 2009;360:1989-2003.
with scleroderma have no obvious skin involvement. Patients with scleroderma plus Copyright © 2009 Massachusetts Medical Society.
evidence of systemic lupus erythematosus, rheumatoid arthritis, polymyositis, or
Sjögren’s syndrome are considered to have an overlap syndrome. This classifica-
tion can be useful, but none of the proposed classifications sufficiently reflect the
heterogeneity of the clinical manifestations of scleroderma.
Scleroderma can lead to severe dysfunction and failure of almost any internal
organ. Here, too, there is considerable heterogeneity (Table 1). Involvement of
visceral organs is a major factor in determining the prognosis. The kidneys, esopha
gus, heart, and lungs are the most frequent targets. Renal involvement can be
controlled by angiotensin-converting–enzyme inhibitors. Severely debilitating esoph-
ageal dysfunction is the most common visceral complication, and lung involve-
ment is the leading cause of death.
The mechanisms underlying visceral involvement in scleroderma are unclear,
despite progress in the treatment of these complications. Relevant data on mecha-
nisms are limited, since most of the available information is derived from cross-
sectional studies and from patients in various stages of the disease, often after
treatment; moreover, there are no satisfactory animal models of scleroderma. Never-
theless, a critical evaluation of the available experimental and clinical data will help
reduce ambiguity and may provide the basis for future studies of scleroderma.
The results of studies of the prevalence and incidence of scleroderma are conflict-
ing because of methodologic variations in case ascertainment and geographic dif-
ferences in these measurements. The available data indicate a prevalence ranging
from 50 to 300 cases per 1 million persons and an incidence ranging from 2.3 to 22.8
cases per 1 million persons per year.6 Women are at much higher risk for scleroderma
than men, with a ratio ranging from 3:1 to 14:1. A slightly increased susceptibility
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The n e w e ng l a n d j o u r na l of m e dic i n e
A B C D E
*
*
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Mechanisms of Disease
a b c
B
Classic Autoantibodies Clinical Features New Autoantibodies Role
Anti–topoisomerase I Diffuse cutaneous scleroderma Anti–endothelial cell Induce apoptosis of endothelial cells
Anticentromere proteins Limited cutaneous scleroderma, pul- Anti–FBN 1 Activate normal human fibroblasts
monary hypertension
Anti–RNA polymerase I/II Diffuse cutaneous scleroderma, renal Anti–MMP 1 and 3 Prevent degradation of ECM proteins
involvement
Antipolymyositis, Polymyositis, calcinosis Anti-PDGFR Stimulate normal human fibroblasts
sclerosis through Ha-Ras-ERK1/2-ROS
Antifibrillarin (U3RNP) Diffuse cutaneous scleroderma, Anti–Nag-2 Induce endothelial-cell apoptosis
internal-organ involvement
Anti-Th/To Limited cutaneous scleroderma, pul-
monary fibrosis
inflammatory cytokines such as tumor necrosis the early stages, whereas type I collagen accumu-
factor α can stimulate or inhibit angiogenesis de- lates in later stages.28,29
pending on the duration of the stimulus.27
Cel l T y pe s in L e sions
Fibrosis
Fibrosis gradually replaces the vascular inflam- Endothelial Cells
matory phase of scleroderma and ultimately dis- Endothelial cells are affected early in scleroder-
rupts the architecture of the affected tissue. It is ma.30 In early lesions there is endothelial-cell
the cause of the main symptoms of the disease. apoptosis, or changes of the endothelial pheno-
Fibrosis in the skin begins in the lower dermis type in the absence of endothelial-cell prolifera-
and upper subcutaneous layer and occurs together tion or precursor differentiation.20,31,32 The mo-
with loss of microvasculature, reduction of ap- bilization of endothelial precursors from bone
pendages, and loss of reticular structure and the marrow is related to disease severity, but recruit-
rete ridges. The composition of accumulated ma- ment of such cells to peripheral vasculature has
trix varies with the stage of the disease. A mix- not been shown.33 The interaction of progenitor
ture of different collagen types, proteoglycans, endothelial cells with platelets and platelet-derived
and elastic fibers including fibrillin is typical of growth factor (PDGF) is essential for the matura-
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1992
Table 1. Clinical Findings in Patients with Scleroderma in Four Countries.*
† This value includes patients with both muscle and articular involvement.
‡ This value includes patients who also had isolated pulmonary hypertension.
§ In the country listed, heart involvement was defined by the presence of arrhythmia requiring treatment.
¶ This value includes patients with one of the following: palpitations, a conduction disturbance, or diastolic dysfunction.
‖ This value includes patients with one of the following: pericarditis, congestive heart failure, severe arrhythmia, or a conduction disturbance.
** The LVEF was less than 50% on echocardiography or there was diastolic dysfunction.
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Mechanisms of Disease
tion and recruitment of endothelial precursors.34,35 an excess of reactive oxygen species. The origin
The perivascular space is a preferred site of early of activated fibroblasts in the skin and internal
lesions in scleroderma. Progressive wall thicken- organs of patients with scleroderma is still debat-
ing and perivascular infiltrates are features of the ed. Fibroblasts may undergo local activation or
vascular lesions in this compartment, indicating originate from resident pericytes, mesenchymal
the involvement of vascular smooth-muscle cells stem cells, or progenitor cells (e.g., fibrocytes) re-
and pericytes. cruited from the circulation.46
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The n e w e ng l a n d j o u r na l of m e dic i n e
matricellular growth factors (CYR61, CTGF, and Extracellular-Matrix Components and Their
NOV [nephroblastoma overexpressed])59 that has Receptors
biologic activities similar to those of TGF-β. En- The hallmark of scleroderma is excessive deposi-
hanced TGF-β and CTGF expression has been tion of extracellular-matrix components, caused
detected in scleroderma lesions, and enhanced by overproduction of collagen and other glyco-
TGF-β signaling in fibroblasts causes skin fi- proteins (e.g., fibronectin and fibrillin).42,43 The
brosis in a mouse model that appears to reca- macromolecular arrangement of collagens in scle-
pitulate the clinical and histologic features of roderma is altered by cross-links that are normal-
scleroderma.60 ly seen in bone but not skin collagen matrix; these
Smad-dependent or Smad-independent signal- cross-links are formed by lysyl hydroxylase 2, the
ing downstream of TGF-β has been extensively level of which is increased in scleroderma.71
characterized in scleroderma cells (Fig. 3).61 In- Extracellular-matrix molecules modulate cellu
hibition of protein kinase C delta, geranyl trans- lar responses by regulating the activity of cytok-
ferase 1, or stress-activated protein kinase p38 ines and growth factors. For example, TGF-β–
eliminates the expression of collagen I and III in fibrillin interaction is required for fibroblast
scleroderma cells.62,63 TGF-β, produced as inac- activation in scleroderma. The extracellular ma-
tive precursor, can be activated by thrombospon- trix also provides points of adhesion, which are
din and by αv β3 integrin, underscoring the inter- bound by integrins, transmembrane receptors
action among cytokines, extracellular matrix, and connecting the extracellular-matrix environment
integrins. The expression of all these molecules to the cytoskeleton, thereby mediating outside-in
is induced in scleroderma.64,65 and inside-out signaling.72 Integrin α1β1 elicits
signals to down-regulate collagen synthesis by
PDGF fibroblasts; α1β1-knockout mice have enhanced
PDGF, which is linked to wound healing and fi- collagen synthesis in wounds.73 Fibroblasts in
brosis, may have a role in scleroderma. The pres- patients with scleroderma have reduced surface
ence of stimulatory antibodies to PDGFR in serum levels of α1β1 integrin, resulting in the failure of
from patients with scleroderma, the strong stimu- integrin to down-regulate collagen synthesis.74
lation by PDGF of the pericyte-to-fibroblast tran Impairment of integrin signaling may amplify
sition,38 the presence of high levels of PDGF and fibrosis in scleroderma. There is accumulating
its beta receptor in skin lesions from patients with evidence that crosstalk between different integrins
scleroderma,66,67 and the beneficial effects of se- and extracellular-matrix molecules determines the
lective inhibitors of PDGF signaling on dermal activity of many cytokines and growth factors that
fibrosis68 all indicate the importance of PDGF in interact directly with responding target cells.64,65
scleroderma. PDGF inhibitors may thus have a Overall, the altered extracellular matrix in sclero-
therapeutic benefit in fibrosis. derma probably provides an environment that
amplifies receptor-mediated cell activation.
Other Cytokines and Biologically Active Substances
Endothelin-1 acts in concert with TGF-β to con- Autoantibodies
vert fibroblasts into myofibroblasts.69 The bene- Scleroderma is associated with several autoanti-
ficial effect of endothelin-1–receptor inhibitors on bodies, some of which are important diagnostic
pulmonary hypertension in patients with sclero- markers. Tests for autoantibodies against topoi-
derma indicates that endothelin-1 is an important somerase I (Scl-70), centromere-associated proteins,
signaling molecule in this disease. Inhibition of and nucleolar antigens can be useful in facilitat-
endothelin signaling may alleviate the overstim- ing the diagnosis and formulating a prognosis. Al
ulation of TGF-β in scleroderma.70 Many other though the autoantibodies correlate with disease
cytokines have been implicated in the angiogene- severity and the risk of specific organ complica-
sis, angiostasis, fibrosis, and localized inflam- tions, their pathogenetic relevance is unclear. Re-
mation in scleroderma. To date, there is no com- cently, autoantibodies against nonnuclear antigens
pelling evidence linking the levels and activity of have been described (Fig. 2), including antibodies
these cytokines to one or more specific patho- against cell-surface antigens. Antibodies against
genic events in this condition (Table 2). PDGFR appear to be agonistic, since they stimu-
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Mechanisms of Disease
late a specific signaling cascade.75 However, the signaling inhibitors has been reported in resistant
specificity of these stimulatory autoantibodies cases of sclerodermatous GVHD.76
remains to be established. The same type of auto
antibodies with PDGF agonistic activity has been R e ac t i v e Ox ygen Specie s
detected in crude immunoglobulin derived from
the serum of patients with sclerodermatous GVHD, High levels of reactive oxygen species and oxida-
and a significant beneficial effect of PDGFR- tive stress have been directly or indirectly impli-
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Table 2. Cytokines, Growth Factors, and Biologically Active Substances Involved in the Pathogenesis of Scleroderma.*
1996
Variable Main Cell Source Pathogenic Relevance Effect in Scleroderma
Interleukin-1 Macrophages, monocytes Has a role in production of interleukin-6 and Constitutively expressed in skin fibroblasts
PDGF-α by fibroblasts
Interleukin-4 Th2 lymphocytes Stimulates fibroblast proliferation, chemotaxis, Increased levels in serum; increased protein and
and collagen synthesis; stimulates production gene expression in skin and in cultured fibro-
of TGF-β, CTGF, and TIMP-1; up-regulates ex- blasts; increased number of interleukin-4–
pression of adhesion molecules by endothelial producing T lymphocytes
cells
Interleukin-6 Fibroblasts, macrophages, endothelial cells, Stimulates collagen and TIMP-1 synthesis; pro- Increased levels in tissue and serum; enhanced
B cells, T cells motes a Th2-polarized immune response production in vitro by PBMC and cultured fi-
broblasts
Interleukin-8 Alveolar macrophages, lung fibroblasts, skin fibro- Serves as a potent chemoattractant and activator Elevated levels in serum, skin specimens, and
blasts of neutrophils; promotes fibroblast chemotaxis bronchoalveolar-lavage fluids
Interleukin-10 Activated B cells, monocytes Promotes a predominant Th2 immune response Increased levels in serum
that induces collagen synthesis
The
Interleukin-13 Th2 lymphocytes Induces fibrosis through a TGF-β–dependent and Increased levels in serum
TGF-β–independent mechanism
Interleukin-17 Th1 and Th2 lymphocytes Induces proliferation of fibroblasts; stimulates fi- Increased levels in serum; overexpressed in skin
broblast production of collagen, interleukin-6,
and PDGF by stimulating macrophage produc-
tion of TNF-α and interleukin-1; induces en-
dothelial-cell production of interleukin-1 and
increased expression of interleukin-6, ICAM-1,
and VCAM-1
TGF-β Macrophages, fibroblasts, T cells, B cells, platelets, Induces proliferation of fibroblasts and production Elevated levels of TβRI in vivo; increased levels of
endothelial cells of CTGF and endothelin-1; stimulates synthesis TGF-β in skin in some studies; elevated ex-
of collagens, fibronectin, proteoglycans; inhib- pression and phosphorylation levels of
n e w e ng l a n d j o u r na l
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broblasts cultured from skin-biopsy speci-
mens
Mechanisms of Disease
growth factor, TβRI transforming growth factor β (TGF-β) receptor type I, Th1 type 1 helper T cells, Th2 type 2 helper T cells, TIMP-1 tissue inhibitor of MMP 1, TNF-α tumor necrosis
monocyte chemoattractant protein 1, MCP-3 monocyte chemoattractant protein 3, MMP matrix metalloproteinases, PBMC peripheral-blood mononuclear cells, PDGF platelet-derived
Increased levels in serum; increased gene expres-
lavage biologic fluids; increased expression in
* CCL2 denotes chemokine ligand 2, CTGF connective-tissue growth factor (also known as CCN2), ICAM-1 intercellular adhesion molecule 1, IGF-II insulin-like growth factor II, MCP-1
broblasts; increased immunostaining in scle-
perturbation of cellular reactive oxygen species
Skin fibroblasts
IGF-II
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The n e w e ng l a n d j o u r na l of m e dic i n e
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Mechanisms of Disease
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The n e w e ng l a n d j o u r na l of m e dic i n e
the structural changes of the vessel and the per- that is the same in both affected and unaffected
turbed control of vascular tone due to an imbal- areas. Many genes can be induced by TGF-β, Ras,
ance between vasodilatory and vasoconstrictive and reactive oxygen species, and an amplification
mediators. At this stage, the patient may have loop linking tyrosine kinase receptors (Ras, reac-
early signs of skin and visceral fibrosis (Fig. 4B). tive oxygen species, and ERK1/2) with receptors
Mesenchymal cells become progressively hy- of TGF-β and CTGF has been found. These cir-
persensitive to cytokines induced by local reactive cuits activate fibroblasts.81,90
oxygen species.98 Cytokines activate mesenchymal Targeted inhibition of signaling pathways by
precursor cells and lead to the transformation of tyrosine kinase inhibitors such as PDGFR, serine–
fibroblasts to myofibroblasts. threonine kinase inhibitors such as TGF-β re-
The continuous synthesis of collagen and ceptors, and farnesyl tranferase inhibitors such
other extracellular-matrix components causes fi- as Ras could interfere with the disease process.
brosis in skin and visceral organs. Profound dis- If autoantibodies turn out to be of functional
ruption of visceral-organ architecture and the relevance in some patients, combinatorial trials
important microvascular alterations are respon- with B-cell–depleting antibodies may also be fea-
sible for tissue hypoxia, which becomes the lead- sible. The identification of biomarkers of disease
ing mechanism in maintaining the production of severity, such as transcription patterns, cellular
reactive oxygen species,99 and for the fibrotic pro- reactive oxygen species, DNA damage signatures,
cess, which occurs through some mechanisms and levels of collagen and α–smooth-muscle actin
that are dependent on and others that are inde- in peripheral monocytes or bioptic fibroblasts
pendent of hypoxia-inducible factor isoform 1α will pave the way toward the development of
(Fig. 4C).100-102 disease-specific and stage-specific targeted ther-
Once the inflammatory reaction subsides, the apies and the identification of well-defined end
disease burns out. Atrophy is now the main der- points for clinical trials.
matologic feature, and the extent of internal- Supported in part by grants from Associazione Italiana per la
Ricerca sul Cancro, Associazione Italiana per la Lotta alla Scle-
organ derangement determines the ultimate prog- rodermia, Ministero Italiano per l’Università e la Ricerca Scien-
nosis (Fig. 4D). Long-term remodeling involving tifica, Fondazione Cariverona, the German Federal Ministry of
modified matrix-metalloproteinase profiles stim- Education and Research, and Deutsche Forschungsgemeinschaft
(SFB 829, to Dr. Krieg).
ulated by T lymphocytes103 may resolve tissue Dr. Gabrielli reports receiving lecture fees from Actelion; and Dr.
fibrosis. Krieg, lecture fees and grant support from Actelion and DIGNA.
No other potential conflict of interest relevant to this article was
reported.
C onclusions We thank Dr. Beate Eckes, Department of Dermatology, Uni-
versity of Cologne, Germany, Dr. Monique Aumailley, Institut für
Several aspects of the pathogenesis of scleroder- Biochemie, University of Cologne, Germany, and Dr. Oliver Distler,
Department of Rheumatology, University Hospital, Zurich, Swit-
ma still await elucidation. Transcription profiling zerland, for reviewing an earlier version of the manuscript and
has revealed a systemic signature of the disease for helpful suggestions.
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