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Introduction Current guidelines recommend immunosuppressive drug treatment in diffuse cutaneous systemic sclerosis, but are less clear on their use in limited cutaneous systemic sclerosis (lcSSc) in the absence of organ complications. We conducted an international survey to understand current immunosuppressive drug prescribing patterns in limited SSc.Material and Methods An electronic REDCap survey was distributed to general rheumatologists in Quebec and Canada, as well as SSc experts affiliated to the Canadian Scleroderma Research Group and the Scleroderma Clinical Trials Consortium. Questions were asked on the use of immunosuppressive drugs in patients with SSc and limited or no skin involvement, and in the absence of arthritis, myositis, myocarditis, interstitial lung disease, or drug contraindications.Results A total of 139 participants responded to the survey, most of whom (94%) were rheumatologists. Use of immunosuppressive drugs in lcSSc to treat cutaneous symptoms varied widely, with 19% of participants responding that they always or most of the time treat, 39% sometimes treat, and 42% rarely or never treat. Conversely, fewer respondents prescribe immunosuppressive drugs to prevent future complications, with 15%, 29%, and 56% always/most of the time, sometimes, and rarely/never treating, respectively.The majority of participants responded that they would likely treat lcSSc if there were tendon friction rubs (87% of respondents), new areas of skin thickening (86%), increasing modified Rodnan skin scores (mRSS) by at least 5 points (84%), high mRSS (84% for 20 points and above, 73% for 15 to 19, 49% for 10 to 14). Respondents were also more likely to treat in the presence of anti-topoisomerase I antibodies (50%) or anti-RNA polymerase III antibodies (49%). Conversely, respondents were less likely to treat if SSc duration was over 7 years (8%) compared to 3-7 years (14%), 18 months-3 years (25%), or below 18 months (33%). Interestingly, a majority of respondents would likely treat lcSSc in the presence of subclinical organ involvement, including subclinical myocardial inflammation (92%), myositis (86%), arthritis (70%), myocardial fibrosis (68%) and interstitial lung disease (68%). The top first-line drugs of choice were mycophenolate mofetil (47%), methotrexate (28%) and hydroxychloroquine (20%).Conclusions This international survey highlights important variation in use of immunosuppressive drugs in lcSSc according to indication and risk factors. High-quality research is needed to produce evidence-based guidelines to harmonize management in lcSSc.Abstract P.216 Figure 1