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For many years, different immunosuppressants have been used in the treatment of early diffiuse cutaneous systemic sclerosis (dcSSc), with the 2009 EULAR (European League Against Rheumatism) recommendations advocating methotrexate for skin manifestations. However, the evidence base for immunosuppression was weak, and immunosuppressants are potentially hazardous. The aim of ESOS (the European Scleroderma Observational Study) was to compare, using an observational approach, the effectiveness of standard treatment approaches (mainly immunosuppressant treatments but including a ‘no immunosuppressant’ option) in the early management of patients with dcSSc, capturing entry and outcome data in a systematic way. Patients were assessed three-monthly for up to 24 months. The primary outcome was the change in modified Rodnan skin score (mRSS). Of 326 patients recruited from 50 centres, 65 were prescribed methotrexate, 118 mycophenolate mofetil, 87 cyclophosphamide, and 56 no immunosuppressant. The main findings were that skin score improved in all treatment groups (but least in the no immunosuppressant category, who also had the highest mortality), and that the relative effectiveness of cyclophosphamide in patients with pulmonary fibrosis was confirmed. Lessons learned from ESOS included:

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