second summative cause (e.g. environmental) leading to the actual development of the disease. Physical causes lead to phenotypic alterations in susceptible cells (e.g. due to genetic makeup), which then effectuate DNA changes that alter the cells' behavior. Diagnosis In 1980, the American College of Rheumatology agreed on diagnostic criteria for scleroderma. Diagnosis is by clinical suspicion, presence of autoantibodies (specifically anticentromere and anti-scl70/antitopoisomerase antibodies), and occasionally by biopsy. Of the antibodies, 90% have a detectable antinuclear antibody. Anticentromere antibody is more common in the limited form (80–90%) than in the diffuse form (10%), and anti-scl70 is more common in the diffuse form (30–40%) and in African-American patients (who are more susceptible to the systemic form). Other conditions may mimic systemic sclerosis by causing hardening of the skin. Diagnostic hints that another disorder is responsible include the absence of Raynaud's phenomenon, a lack of abnormalities in the skin on the hands, a lack of internal organ involvement, and a normal antinuclear antibodies test result. Treatment No cure for scleroderma is known, though treatments exist for some of the symptoms, including drugs that soften the skin and reduce inflammation. Some patients may benefit from exposure to heat. Holistic care of patients comprising patient education tailored to patients' education level is useful in view of the complex nature of the disease symptoms and progress. Topical/symptomatic Topical treatment for the skin changes of scleroderma do not alter the disease course, but may improve pain and ulceration. A range of nonsteroidal anti-inflammatory drugs, such as naproxen, can be used to ease painful symptoms. The benefit from steroids such as prednisone is limited. Episodes of Raynaud's phenomenon sometimes respond to nifedipine or other calcium channel blockers; severe digital ulceration may respond to prostacyclin analogue iloprost, and the dual endothelin-receptor antagonist bosentan may be beneficial for Raynaud's phenomenon. Skin tightness may be treated systemically with methotrexate and ciclosporin. and the skin thickness can be treated with penicillamine. Kidney disease Scleroderma renal crisis (SRC) is a life-threatening complication of systemic sclerosis that may be the initial manifestation of the disease. Renal vascular injury (due in part to collagen deposition) leads to renal ischemia, which results in activation of the renin-angiotensin-aldosterone system (RAAS). This raises blood pressure and further damages the renal vasculature, causing a vicious cycle of worsening hypertension and renal dysfunction (e.g., elevated creatinine, edema). Hypertensive emergency with end-organ dysfunction (e.g., encephalopathy, retinal hemorrhage) is common. Thrombocytopenia