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This woman in her 50s presented with bilateral digital shortening, sclerodactyly, and pallor of the fingertips. She described a 30 year history of progressive finger skin thickening and hardening, and Raynaud’s phenomenon. She had a family history of connective tissue disease, had never smoked, had no respiratory symptoms, and had not previously sought medical care for her skin changes. Laboratory tests showed positive antinuclear and anti-Scl-70 antibodies, with weakly positive anti-Ro-52 antibodies. Results of an antiphospholipid screen were negative. Hand x ray imaging indicated marked acro-osteolysis of the distal and middle phalanges with marginal osteophyte formation (fig 1). She was diagnosed as having systemic sclerosis, and started on prednisone, methotrexate, hydroxychloroquine, and calcitriol. She also began treatment with beraprost sodium, a vasodilator and antiplatelet agent that is not licensed in the UK. She remained stable over a 14 month follow-up.