Botulism Gave Us Botox. And Now Collagenase...

Clostridium histolyticum is the deadly cousin to the germ that causes botulism.  In it's worst form, it is responsible for gas gangrene of the tissues.  Yet, both of these deadly germs have been tamed to create medicines that improve our lives.

People with Dupuytren's contracture get "clenched fingers" due to a hereditary skin problem of the hand.  Previously, surgery was the only option for these patients.  However, there are risks, including nerve or artery damage.   In the medical literature, 33% to 100% of patient's have the problem come back!  It's no wonder that patients and surgeons have been looking for a new treatment.  

A contracted ring finger from Dupuytren's contracture.  Image used with permission.

Xiaflex is a newer option for people who have Dupuytren's contracture.  It is derived from Clostridium histolyticum, a bacterium.  However, there are no bacteria in the final product.  It is one of three options now available for patients with Dupuytren's contracture.  Xiaflex is injected  in the doctor's office.  There can be some pain associated with the injection, but most people report that it is minor and temporary.  Over the next day or so, the Xiaflex does its job, dissolving and weakening the contracted cord.  Patients are advised that the hand will become swollen at the injection sites.  They are instructed to avoid any vigorous activity with the hand.  Some patients can experience an allergic reaction to Xiaflex resulting in a skin rash, swollen face, chest pain, dizziness, or breathing trouble.

Within 24-72 hours of the first injection, the patient comes back to the office to have the cord ruptured.  Under local anesthesia, the doctor straightens the finger.  Since the collagenase (Xiaflex) has weakened the cord, it usually ruptures with moderate pressure of about 10 pounds.  In some really tough cords, a second or third injection might be required.


Results have been similar to surgery.  At 5 years after Xiaflex, 47% had a recurrence of >20 degrees.  About three quarters of the patients are satisfied with the procedure and say they would have it again if given the choice.  On the other hand, 17% of patients regretted their choice and would not have the same treatment given the choice.

The other option for Dupuytren's contracture is percutaneous needle fasciotomy.  This is also an office procedure.  It also carries some risks including tendon and nerve damage.  The recurrence rates are quite variable but have been reported anywhere from 43% to 71%.  This study showed that percutaneous needle fasciotomy is as good or better than Xiaflex.

Conclusions:  Dupuytren's contracture is an inconvenient disease that can cause clenched fingers.  The problem is not usually debilitating and treatment can be delayed a long time or avoided altogether.  All of the treatments have risks and the recurrence rates are high.  In light of this, the treatment with the lowest side effect profile wins out.  In my opinion, Xiaflex often has a lower impact on patients’ lives than surgery with comparable long term recurrence rates.  It can be used on the majority of contractures that I see in my practice.  In most cases, I believe Xiaflex is safer than percutaneous needle fasciotomy.  I still use percutaneous needle fasciotomy, especially if the cord is mostly in the palm and spares the finger.  In some cases of very contracted cords or cords that have previously been treated and recurred, surgery may be the only option.  In very small cords in the palm, Xiaflex or percutaneous needle aponeurotomy are good options.

Update:  I used to have patients wear splints at night for a few months after the injection.  However, this study showed no advantage to the splints and I no longer recommend them.

Additional note:  Xiaflex is now approved for the treatment of Peyronie's disease which causes a curvature of the penis.  I don't treat that condition, but for many men, this will be a welcome alternative to surgery.

Disclaimer:  Dr. Sohn has no financial or other conflicts of interest related to the treatments discussed here.