How do you approach immunosuppression targeting skin thickening in scleroderma after the initial three years of onset?  

I think there is still a role for trial of immunosuppression in the case of a patient who has diffuse skin disease and has signs of progression or lack of improvement even if it is beyond 3 years. If a patient has limited skin distribution (i.e., only sclerodactyly) or the skin has not changed over ...