Radiation Therapy for Dupuytren Disease: A Systematic Review of Clinical Outcomes and Adverse Effects

Dupuytren disease (DD), a benign fibroproliferative disorder, affects an estimated 12% to 29% of individuals aged 55 to 75 years in Western countries. ¹ It is more common and severe in men around the age of 50, with women typically developing a severe onset later on in life.

DD presents initially in a singular hand, with 80% of affected individuals eventually having features of DD in both hands. ² Symptoms of fibrosis can occur in any location but are most common in the middle of the palm, progressing to the 4th and 5th fingers. Once one or more nodules form in the palm, they are subsequently followed by cords that develop into the distinctive digital contractures. ³ About 25% of people with DD experience discomfort or pain, with inflammation, tenderness, burning, or itching often associated with affected joints and areas of skin. ²

The main cause of DD is not yet known. However, the development of fibrosis is associated with inflammation, and several proinflammatory cytokines have been associated with DD, including the elevated expression of TGF-β1, α-SMA, and canonical Wnt signaling. ⁴ DD is also associated with environmental factors such as smoking, alcohol consumption, aging, trauma, and repetitive use of the hand in various physical occupations. ^3,5,6 There is ongoing evaluation of genetic risk factors, with a recent meta-analysis of 6 genome-wide association studies identifying approximately 85 single-nucleotide polymorphisms in 56 loci, implicating the hedgehog and Notch signaling pathways in DD disease etiology. ⁷ DD is associated with other disorders of the connective tissue, including Garrod pads, Ledderhose disease (plantar fibromatosis), and Peyronie disease in males. ²

The early stages of this disease, characterized by nodule formation without contracture, currently lack standardized clinical criteria or treatment options. Surgical intervention, the mainstay of DD treatment, is considered when the patient’s finger has lost 30° of metacarpophalangeal or interphalangeal extension of the joint. ⁸ Surgery is not typically advocated for early stages of the disease unless it is accompanied by persistent pain or discomfort, as the early proliferative stage with high cellularity has been associated with higher rates of recurrence. ⁹ Other treatment options range from minimally invasive to extensive surgical approaches. Collagenase clostridium histolyticum (Xiaflex) offers a nonoperative option through the enzymatic weakening of the cord. However, as a nonspecific collagenase, its mechanism can affect adjacent collagen-containing tissues and contribute to local adverse effects. Steroid injections such as triamcinolone acetonide are injected directly into nodules. ¹⁰ Percutaneous needle aponeurotomy (needling) involves mechanical separation of the pathologic cords using a fine needle, allowing digital extension without incision. Surgical options include fasciectomy, which entails partial or complete removal of the fibrotic tissue. While complete fasciectomy is associated with lower long-term recurrence compared with partial fasciectomy, this benefit is often outweighed by substantially greater acute morbidity and late complications.

Recurrence rates also differ based on treatment modality. When treated with needling, the 5-year recurrence rate of DD is reported to be 65%. Recurrence rate is 75% with collagenase injections and 10% to 75% for treatment with fasciectomy. More invasive surgery is thought to increase the risk of acute and late toxicity. ¹¹ Furthermore, disease reactivation can occur following invasive interventions, such as collagenase injection, fasciotomy, and fasciectomy, contributing to the challenge of durable disease control.

In European countries such as Germany, radiation therapy (RT) is considered a preferred treatment option for patients with earlier stages of DD not meeting the criteria for surgical interventions. This approach has been attracting attention from the United States through the use of social media. ¹² Recent emerging studies, including DEPART, a randomized controlled trial, have begun to evaluate the potential benefit of RT in the management of early stage DD. ¹³ However, the majority of available evidence assessing outcomes in patients receiving RT for DD consists of retrospective analyses and single-institution prospective studies. Controversy exists regarding the field design and standard of approach for these studies, including the treatment area, dose, and fractionation recommended for the course of treatment. Although various RT techniques have been described, split-course RT is a commonly reported strategy; however, considerable variation in dose and fractionation exists across studies. This systematic review evaluated the use of RT in DD, in an effort to provide an updated evidence base for this technique in DD treatment.

Using a method of screening based on Participants, Intervention, Comparison, Outcomes, and Study design, 4808 articles were initially considered for eligibility of analysis via search engines PubMed and Google Scholar throughout September 6, 2025, to November 6, 2025. This was performed using the free-text phrase Dupuytren’s Contracture Radiation Therapy, entered as a single search string without conjunctions. Additional records were then identified through backward citation chaining from key studies and reviews, independently screened, and assessed against this review’s prespecified criteria.

A total of 4808 records were identified through the utilization of research database screenings. Of those, 20 studies met the inclusion criteria and were included in the final analysis: 2 prospective clinical studies, ^14,15 17 retrospective cohort/case series studies, ^16-32 and 1 cross-sectional patient-reported survey study. ³³ Among the 17 retrospective studies, 2 were written by the same author. ^21,22 Among all included studies, 6 were in German ^{16,24,26,29-31} and 1 in Italian. ²⁰ When needed, an image-capturing feature of Google Translate (Google LLC, Mountain View, CA) was used to extract the necessary data from photocopied versions of the documents. Data were compiled with all included studies and respective reported outcomes (Table 1).

In this systematic review, we analyzed 20 studies consisting of prospective, retrospective, and cross-sectional survey studies evaluating the effects of using RT for DD. Although different staging systems were used depending on the study’s design, a majority (68%) of treated patients were reported to either be in the early stages of DD (to the study’s discretion) or ≤ stage 1 in the respective classification system. Overall, 65% of patients in the 20 studies reported the regression of symptoms as the most common outcome. It is hypothesized there is a therapeutic window for RT in patients with early stage DD, as early stage patients have decreased progression (Tubiana stage N/I progression after RT was 30% compared with 75% in stage 2-4). ¹⁴ As RT preferentially affects rapidly proliferating tissues, RT would be more efficacious in the early disease state of high cellularity and mitosis than in later-stage disease characterized by low cellularity and high collagen concentration. Among the 13 studies deemed successful, 2 reported a 100% regression outcome. ^19,23 Both studies comparatively share a smaller cohort size of ≤5 irradiated hands, but Ciernik’s 2021 study included a wider array of disease stages in its patient demographics (Table 1). ¹⁹ Despite the overwhelming unanimity of results, the study’s small cohort sizes limit the ability to draw widespread conclusions.

Only one study reported disease progression as the most common outcome following RT. In the retrospective analysis by Weinzierl et al, nearly all irradiated hands demonstrated progression as their primary outcome during long-term FU, which the authors attributed to the approximate 7-year period in which patients were not monitored between completion of RT and the first FU assessment. Importantly, the observed pattern and rate of progression did not differ meaningfully from the natural history of early DD, suggesting that RT in this cohort did not alter long-term disease behavior. ³¹

It is important to recognize that not all patients with early stage DD experience progression when left untreated. A meaningful proportion can remain clinically stable for years. As the Seegenschmiedt cohort demonstrates, approximately 50% of untreated patients were reported to show no progression of symptoms during extended FU. ¹⁵ Given this variability, RT should not be considered for patients with stable and asymptomatic disease. Instead, it is best to make treatment decisions based on documented, active disease progression characterized by clinical criteria and worsening changes in hand grip strength, finger span or finger-raise measurements, or contracture deformity. ³⁶ This will ensure that RT is only offered when biologically and clinically justified.

Chronic side effects were less commonly reported with a calculated average of 22.8% in patients, falling between an encompassing range of 13% to 30% experiencing persistent changes after treatment. Common long-term effects consisted of symptoms such as altered heat sensation, pain, or other acute effects. The timing for FU evaluation of chronic symptoms varied or was not explicitly stated. In the UK, the National Institute for Health and Care Excellence cautions there is limited evidence for the safety of RT in patients with early DD, with a discussion of theoretical risk on the development of RT-induced cancer in the long-term effects. ³⁷ However, no cases of long-term cancer caused from RT of DD have been reported.

A high risk of bias presents an additional challenge when interpreting the results. ⁸ In the 2 prospective clinical studies conducted by the same author, methods and outcomes were reported comprehensively, in contrast to the majority of retrospective studies, which frequently lacked methodological detail and specificity. ^14,15 Patient-reported outcome measures were often subjective and dependent on individual patient perception, rendering them more susceptible to response bias. ³³ Furthermore, substantial heterogeneity was observed across the included studies with respect to patient demographics, treatment parameters, adjunctive therapies, study endpoints, and FU duration. Consequently, drawing precise conclusions from the currently available published data remains challenging.

Several prospective studies on RT in DD are underway. The ongoing DEPART randomized clinical trial will provide prospective randomized data on RT efficacy both as definitive treatment and as adjuvant treatment after needle aponeurotomy. It will also explore the adverse effects of DD following RT as described previously. ³⁴ Furthermore, the University of Minnesota’s ongoing Post-contracture Release RT for DD study has been evaluating efficacy for postoperative RT through an observational prospective pilot study format (NCT04122313). ³⁵ Similarly, the Dartmouth-Hitchcock Medical Center has an ongoing study evaluating RT for Dupuytren’s Contracture Following Non-Surgical Release (NCT06330545). ³⁸

Taken together, the available evidence across studies and existing trials suggests that RT may be most beneficial in earlier, proliferative stages of DD, when nodules are active, but contractures are minimal (< 10 degrees). RT should be recommended when there is documented active progression in patients, ideally captured using standardized clinical criteria (changes in hand grip strength, finger span or finger-raise measurements, or contracture deformity). If RT is used, current data support moderate-dose regimens (30 Gy in 10) fractions in a split-course modality (6-12 weeks break between 5 fraction courses) or 21 Gy in 7 fractions without break. A split-course approach is thought to best balance both risk and therapeutic effects. Patients who are unable to receive the split course regimen could be considered for the 21 Gy in a 7 fractions regimen, although there is a slightly increased risk of contracture progression. ¹⁵ Treatment planning should include fields delineated based on the fascial thickening seen on CT planning and palpation of nodules/cords plus margins. ³⁶

Using CT-based planning techniques, prospective studies and practice guidelines recommend the application of bolus and coverage of the involved palmar fascia with the >90% isodose line. ^13,36 However, the evidence base remains limited by unspecified outcome measures and inconsistent reporting of progression, regression, and long-term control. To improve the field, future prospective, standardized trials are needed, using uniform definitions of disease activity, consistent functional outcome measures, and detailed long-term FU to determine whether RT alters the natural history of early DD. The development of core outcome sets and universal consensus based on clinically meaningful endpoints will be essential for future progress.

In summary, the use of early stage RT as a noninvasive method to treat DD holds promising potential as an alternative to invasive surgery. However, debates over the variability of study design, FU duration, and outcome reports limit the strength of existing evidence in current literature. To better assess long-term efficacy for prophylactic therapy and treatment, future studies should adopt a standardized protocol, consisting of larger and controlled patient populations, to produce consistent and high-quality results. The future of these results will be essential to guide the next steps in clinical decision-making.