Sicca symptoms in inflammatory connective tissue diseases

Sicca symptoms (eg dry mouth or dry eyes) are caused by exocrine gland dysfunction, particularly of the salivary or lacrimal glands. Dryness of mucosal membranes may be severe and cause ulceration and scarring. Sicca may also involve the upper airways and vagina. Referral to a specialist is recommended.

Sicca symptoms are common in all inflammatory connective tissue diseases, but are most severe in Sjögren syndrome. Sicca symptoms can also occur in people who do not have inflammatory connective tissue disease, particularly older people; in these people, symptoms are not usually progressive and not associated with positive antinuclear antibody (ANA) results.

Nonpharmacological management for sicca symptoms may include:

• wearing sunglasses outdoors to avoid wind-drying effects on the eyes
• avoiding dry and heated air, cigarette smoke, and drugs with anticholinergic effects (eg tricyclic antidepressants, antiparkinsonian drugs)
• ensuring adequate oral hydration and good dental hygiene, including regular dental review to prevent dental caries (see Management of dental caries)
• increasing awareness of extra care required to avoid damage to the eyes and mouth if undergoing surgery.

Pharmacological management for dry eyes (keratoconjunctivitis sicca) includes frequent use of ocular lubricants (artificial tears). Multiple preparations are available, including drops, gels and ointments. Eye drops need to be applied several times a day. Gels and ointments are retained in the eye for longer and require less-frequent administration than drops; however, they are associated with some blurring of vision and can leave a crust on the eyelashes. Gels and ointments may be most useful at night because of better tolerance and longer duration of effect. A trial of several different preparations may be required to determine the most effective and best-tolerated preparation for an individual. People may become sensitised to the preservatives in multi-use eye drops or gels, especially if they are using them more than 3 or 4 times daily. Switch these people to preservative-free, single-use vials.

Refer patients with severe keratoconjunctivitis sicca to an ophthalmologist. Ciclosporin eye drops can improve tear flow by reducing inflammation in the lacrimal gland, but are not widely available and must be prescribed by an ophthalmologist. Occasionally symptomatic relief can be achieved by surgical insertion of punctal plugs into the lacrimal duct.

Pharmacological management for dry mouth (xerostomia) is difficult to manage and available preparations are often poorly tolerated. Preparations include sprays, mouthwashes and gels, and artificial saliva. Patients may need to trial several preparations before they find the most effective and well-tolerated preparation. For more information, see Management of dry mouth.

Pharmacological management for vaginal dryness is usually managed with intravaginal lubricant jellies. In postmenopausal females, consider the use of intravaginal estrogen—see Intravaginal therapy for menopausal symptoms for more details.