My first Dupuytren palm nodule. What will to happen to me?
Most Dupuytren disease starts as a nodule.
Some nodules go away without any treatment.
Some nodules develop minor cords and then seem to stop.
Some nodules are the first sign of severe Dupuytren disease.
Which is it going to be? Without a biomarker, we can only guess at the risk. Physicians make an educated guess based on risk factors for recontracture after surgery. These risk factors are called Dupuytren diathesis factors. Different factors have been reported by different research groups and include any of these:
⋅ Close blood relative with Dupuytren disease
⋅ Younger than 50 when Dupuytren first appears
⋅ Both hands involved
⋅ More than two fingers involved
⋅ Male gender
⋅ Knuckle pads
⋅ Ledderhose disease
⋅ Dupuytren involving the thumb
In general, the more diathesis factors one has, the greater the risk of recontracture after a Dupuytren contracture procedure.
Not everyone agrees on all of these or their relative importance. Family history and age of onset seem to carry the most weight. Some factors, including frozen shoulder, Peyronie disease, and diabetes aren’t on this list because they have yet to be confirmed as independent risk factors for recontracture after surgery. They may be associated with Dupuytren disease, but not necessarily with recontracture after treatment.
What do surgical risk factors have to do with a new nodule? Without a biomarker, diathesis factors are all we have to go on, assuming that things associated with aggressive disease after a procedure are also associated with aggressive disease leading to contracture. That’s a big assumption, and the truth is that, although much is known about what happens after procedures for Dupuytren contracture, almost nothing is known about what happens before treatment. There are only two articles published in peer reviewed medical journals with meaningful data on long term outcome of early untreated Dupuytren disease:
Gudmundsson KG, Arngrimsson R, Jónsson T. Eighteen years follow-up study of the clinical manifestations and progression of Dupuytren’s disease. Scand J Rheumatol. 2001;30(1):31-4. (Pubmed abstract) (Full text PDF)
Here is the key data from these studies:
- Gudmundsson reported “Of the 75 men who had palmar nodules or fibrous cords in 1981, a total of 26 (34.6%) had developed contracted fingers or had been operated in 1999.”
- Reilly reported 59 patients with only a nodule at average followup of 8.7 years, 7 had spontaneous resolution of nodules, and 5 had developed MCP and/or PIP contracture.
Putting these together, my conclusion is that in this tiny sample, the risk of progression from nodule to contracture averages just less than 20% per decade. This is a soft prediction at best. It doesn’t break down the effect of diathesis factors. The great variation in Dupuytren biology means that it’s unlikely that any study analyzing less that a few hundred outcomes is large enough to have solid statistical significance. However, it’s a starting point. It’s also a reference point for any preventative treatment approach, because it does clearly show that some nodules go away with no treatment, and that few people progress to contracture within a few years of their first nodule.
Wouldn’t it be great to have a better way to predict risk, a smart guide for what to?
Imagine this situation: person develops nodule, goes to physician, has a biomarker test.
Scenario 1: Biomarker shows low risk of progression. No treatment indicated.
Scenario 2: Biomarker shows high risk for progression. Preventative early stage treatment (cortisone injections, radiotherapy, some new medicine) recommended because the benefit of treatment is justified. Because this is evidence-based, treatment is covered by insurance.
That’s not fantasy – that is exactly how biomarkers are used to manage other diseases. The same can be done for Dupuytren disease – it’s just a matter of doing the work to make it happen. This is the reason that as many people as possible need to sign up for the free International Dupuytren Data Bank – http://DupStudy.com. Enroll today and tell everyone you know with any Dupuytren disease – early, late, with or without treatment – to do the same. Tell anyone with a confirmed diagnosis of Ledderhose disease – with or without Dupuytren disease – to do the same. The sooner the data is collected, the faster the research can proceed. Together, we will find a cure.
Charles Eaton MD