What's behind these skin changes, ptosis, and voice disorder?

A process of elimination gets to the source of these symptoms.

Marjorie is 73 and has had scleroderma for nearly 10 years.

Mature woman eyes closed

She manages her Raynaud’s phenomenon using gloves in cold conditions and has never had evidence of digital vasculitis.

Her only regular medication has been pantoprazole for reflux oesophagitis.

Otherwise the condition is stable, with no evidence of pulmonary or renal complications. However, in recent months, Marjorie has noticed skin changes across the dorsum of her hands, extending onto her forearms.

She has also developed