Clinical Notes : Dermatology

201. Managing Sicca Syndrome

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Sjogren's vs. Sicca Syndrome

 

Sicca is a word derived from the Latin siccus, meaning “dry.”

Dryness of the exocrine glands, particularly the eyes and mouth, is referred to as “sicca syndrome” or “sicca complex” when there is no evidence of autoimmune disease present. 

 

While sicca symptoms occur in the vast majority of Sjögren’s patients, not everyone with these symptoms has Sjögren’s. Because of this, it is important to establish an autoimmune cause for the dryness. 

Sometimes other causes may be found, such as radiation therapy to the head, certain medications, or Hepatitis C or HIV infections.

If no cause is found, the patient should be followed carefully for possible Sjögren’s because it sometimes takes years for the diagnosis to become clear (27).

Sicca Syndrome

 

Sicca syndrome describes problematic symptoms of dry eyes and dry mouth (xerostomia).

 

Symptoms are reported by up to 20% of the general population, increasing to 50% in older people as a result of rising polypharmacy and co-morbidity.(1,2)

 

In 2019, 480,000 prescriptions were issued in England for dry mouth and 4.4 million for dry eyes, at a cost to the NHS of £3.4 million and £22 million, respectively.(3) 

 

Despite this, no consensus guideline exists for the management of sicca syndrome in primary care.

This article aims to summarise the available evidence and provide tips about managing the condition in primary care. (26).

 
 

1. Listen to the patient’s experience

Sicca syndrome can have a significant impact on the patient’s quality of life.

 

Dry mouth can lead to problems with taste, chewing, swallowing, speaking, and halitosis, while dry eye causes ocular discomfort, blurring of vision and, in severe cases, damage and scarring to the cornea.(1,2,4)

Few practitioners have the experience or equipment to perform objective measurements of salivary flow or tear film breakdown.

It is therefore appropriate to classify the severity of symptoms according to the patient’s reports.

2. Consider and address underlying causes where possible

Sicca syndrome may be idiopathic, iatrogenic, or occur secondary to Sjӧgren’s syndrome.

 

Underlying causes are listed in Table 1, along with associated clinical features.

 

Table 1 : Underlying causes of Sicca Syndrome (4-19)

 
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3. Consider lifestyle measures and health promotion

Oral health is of particular importance in those with xerostomia.

Dietary sugars and acidic foods should be avoided as they encourage bacterial growth in patients already susceptible to dental decay.

Teeth should be brushed twice a day with a soft toothbrush followed by rinsing with water or a fluoride or antiseptic mouthwash. Dentures should be removed at night and cleaned in accordance with dentists’ instructions.(6)​

 

Patients should be advised about maintaining adequate hydration.

Sipping on water or sucking ice chips can help people who need to restrict fluid, such as those with congestive cardiac failure.

 

A petroleum-based jelly can be helpful for cracked lips, while a water-based lubricant is appropriate for those on oxygen therapy.(6)

Smoking, caffeine, and alcohol are considered irritants and should be avoided or minimised.

 

Reducing screen time and contact lens wearing may help symptoms of dry eye.(1)

 

4. Understand how dry eye treatments work

The tear film is made up of three layers covering the cornea and exposed conjunctiva: an inner mucin layer, a middle aqueous layer, and an outer lipid or meibomian layer, which prevents evaporation.(1,20)​

Deficiency of the aqueous layer occurs because of reduced production in the lacrimal glands, for example, in Sjӧgren’s syndrome or because of excessive evaporation when the lipid layer is reduced.(1) 

 

Measures designed to target aqueous deficiency may include humidification of the environment, wearing glasses to reduce evaporation, punctal plugging, and topical eye drops.(1,4,20) 

 

Meibomian gland treatments may include lid hygiene and massage, or oral antibiotics such as doxycycline.(21)

 
 

How to do Eyelid massage and Meibomian Gland Expression for Dry Eyes and Eyelid Stye

 

Nighttime routine for dry eyes

5. Use a stepwise approach to prescribing eye drops

Artificial tears have been shown to slightly prolong the breakdown time of the tear film and reduce signs of ocular damage.(1)

 

Higher viscosity drops are designed to evaporate more slowly, providing longer term lubrication. However, there is not yet sufficient evidence to support the use of one product over another.(1,20)

Over-the-counter preparations may be as effective as those available only on prescription;(20) therefore, clinicians should be guided by patient-reported symptoms and consider impact on quality of life.

Where symptoms persist despite topical treatments, it might be worth trialling a preservative-free treatment as irritation and allergy to preservatives can develop over time.(1,5,20)

Where this does not produce satisfactory symptom control, a higher viscosity product and/or a combination of treatments can be tried.

 

Eyedrops viscosity

 
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Escalating treatment according to symptoms severity (4, 5)

 
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6. Understand how treatments for dry mouth work

 

Saliva is produced continuously by the parotid, submandibular, and sublingual glands, with production increased by the sensory input of taste and smell, and the mechanical action of chewing.(22)

Salivary substitutes work by coating mucous membranes to reduce salivary loss by evaporation.

 

Salivary stimulants work to increase production in those with residual salivary gland function, either pharmacologically or by mechanical action, such as chewing gum.(2)

Prescribing dry mouth treatments

A 2011 Cochrane review (2) evaluating topical treatments for xerostomia did not find strong evidence that topical treatments were superior to placebo, and there were few head-to-head trials comparing different products.

 

Clinicians should, therefore, aim to try products with different active ingredients, as outlined in Table 2, until a patient preference can be established.

 

Table 2: Examples of saliva substitutes (23)

 

Pilocarpine is a muscarinic M3 receptor agonist which stimulates salivary flow. (24)

 

It is licensed for use in Sjӧgren’s syndrome and for xerostomia after radiotherapy.(25) 

 

However, its use is contraindicated in poorly controlled asthma, chronic obstructive pulmonary disease, cardiorenal disease, and in those with uveitis.

 

Side-effects include diarrhoea, nausea, hyperhidrosis, blood pressure instability, and disorders of vision, and it may take up to 3 months for the full effect of treatment to be seen.(25)

7. Review the patient regularly

To ensure maximum symptomatic benefit and to reduce waste, the efficacy of prescribed treatments should be reviewed after 4–6 weeks, and if symptoms remain inadequately controlled, consideration should be given to switching products.(5)

 

8. Screen for other manifestations of sicca syndrome impacting on quality of life

The symptoms of sicca syndrome may extend beyond dry eyes and mouth to include chronic cough and vaginal dryness in women.(4)

 

These symptoms should be screened for as part of routine review and appropriate symptomatic treatments offered.

 

9. Know when to refer

Same-day ophthalmology referral should be considered where there is moderate/severe eye pain or photophobia, unilateral red eye, or reduced visual acuity.1 Indications for non-urgent referral to ophthalmology include:(4,5)

  • underlying pathology requiring specialist input, such as Sjӧgren’s syndrome

  • treatment failure

  • diagnostic uncertainty

  • deteriorating vision

  • evidence of corneal damage.

 

Urgent medical referral is required for dry mouth where there is significantly reduced oral intake, mucositis causing severe pain, suspected neutropenic mouth ulcers, or severe/persistent candida or herpes simplex virus infection.(6) 

 

Referral to a dietitian and/or speech and language therapy service may be appropriate when there is reduced nutritional intake, dysphagia, or speech impairment.(6)

 

Summary

Sicca syndrome is a common condition with a range of aetiologies including prescribed medications, diabetes, ophthalmological disorders, and Sjӧgren’s syndrome.

 

First-line management strategies include lifestyle modification and addressing underlying causes where possible.

 

A wide range of artificial saliva and tear replacement products are available but in the absence of evidence directly comparing them, it is appropriate to trial a range of products and prescribe in accordance with patient preference.

 

Clinicians should seek specialist review where there is treatment failure, diagnostic uncertainty, or evidence of complications such as deteriorating vision.

 
 
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1. Drug and Therapeutics Bulletin.

The management of dry eye.

BMJ 2016; 353: i2333.

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2. Furness S, Worthington H, Bryan G et al.

Interventions for the management of dry mouth: topical therapies.

Cochrane Database Syst Rev 2011; 12: 

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3. Prescription cost analysis—England 2019.

NHS Business Services Authority.

(accessed 10 November 2020).

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4. Price E, Rauz S, Tappuni A et al.

The British Society for Rheumatology guideline for the management of adults with primary Sjӧgren’s Syndrome.

Rheumatology 2017; 56: e24–e48.

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5. Dry eye syndrome.

NICE Clinical Knowledge Summary.

(accessed 10 November 2020).

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6. Palliative care—oral: dry mouth.

NICE Clinical Knowledge Summary.

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7. Miranda-Rius J, Brunet-Llobet L, Lahor-Soler E, Farré M.

Salivary secretory disorders, inducing drugs, and clinical management.

Int J Med Sci 2015; 12 (10): 811–824.

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8. Hyperglycaemia (high blood sugar).

NHS UK website.

(accessed 26 November 2020).

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9. Diabetes—type 2.

NICE Clinical Knowledge Summary.

(accessed 26 November 2020).

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10. Dry eyes.

Mayo Clinic.

(accessed 26 November 2020).

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11. Blepharitis.

NICE Clinical Knowledge Summary.

(accessed 26 November 2020).

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12. Meibomian cyst (chalazion).

NICE Clinical Knowledge Summary.

(accessed 26 November 2020).

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13. Laser eye surgery and lens surgery.  

NHS.uk.

(accessed 26 November 2020).

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14. Candida—oral.

NICE Clinical Knowledge Summary.

(accessed 26 November 2020).

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15. Generalized anxiety disorder.

NICE Clinical Knowledge Summary.

(accessed 26 November 2020).

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16. Burning mouth syndrome—information for patients.

Oxford Radcliffe Hospitals NHS Trust.

Oxford University Hospitals NHS Foundation Trust, 2011. 

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17. Scully C.

Drug effects on salivary glands: dry mouth.

Oral Dis 2003; 9: 165–176.

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18. Tan E, Lexomboon D, Sandborgh-Englund G et al.

Medications that cause dry mouth as an adverse effect in older people: a systematic review and meta-analysis.

J Am Geriatr Soc 2018; 66: 76–84.

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19. Dempsey O, Paterson E, Kerr K, Denison A.

Sarcoidosis.

BMJ 2009; 339: b3206.

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20. Pucker A, Ng S, Nichols J.

Over the counter (OTC) artificial tear drops for dry eye syndrome.

Cochrane Database Syst Rev 2016; .

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21. When should I suspect blepharitis ?

NICE Clinical Knowledge Summary.

(accessed 14 November 2020).

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22. Iorgulescu G.

Saliva between normal and pathological. Important factors in determining systemic and oral health.

J Med Life. 2009; 2 (3): 303–307.

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23. Artificial saliva products.

NICE BNF.

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24. Pronin A, Wang Q, Slepak V.

Teaching an old drug new tricks: agonism, antagonism, and biased signaling of pilocarpine through M3 muscarinic acetylcholine receptor.

Mol Pharmacol 2017; 92 (5): 601–612.

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25. Pilocarpine.

NICE BNF.

(accessed 10 November 2020).

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26. Sjogren's Vs. Sicca Syndrome

Sjogren's Syndrome Foundation

Posted on Thu, Aug 21, 2014

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27. Top tips: sicca syndrome

A. MacCormac

Guidelines in Practice

22 December 2020

Access

Ireland notes.png

Low viscosity : Liquifilm tears  

Thin-Medium viscosity : Optive

Thick-Medium viscosity : Hylo Forte

High viscosity : Xailin Night

 

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