SICCA (DRYNESS)
Key Concepts
What Is Sicca? - Sicca means dryness in Latin. Sjogren's-related sicca is often mistakenly seen as just a simple case of dry eyes and dry mouth. However, it is a far more complex than a simple lack of secretions, which is why treatments like artificial tears and oral lubricants may not be adequate on their own.
Sicca is just one part of Sjogren's. Not everyone with Sjogren’s has sicca, although most do by the time they are diagnosed. Systemic (non-sicca) manifestations can be found in nearly every patient who is carefully evaluated. Sjogren’s is always systemic, even in patients who have sicca-dominant disease.
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Ocular Sicca - Can damage the eye surface and impair vision.
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Oral Sicca - When not managed aggressively, oral sicca may lead to severe dental decay (caries) or even loss of teeth.
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Sicca Of The Airways - Severe airway dryness damages the mucosal surfaces of the airways and may damage nerves.
The Full Scope of Sicca
When doctors use the term "sicca", they are typically referring to dry eyes and dry mouth. However, Sjogren's sicca is more than just a lack of secretions and is not limited to the eyes and mouth. Sicca is caused by a combination of dryness (a loss of secretions), inflammation, neuropathy, dysfunction of the autonomic nervous system (DYSAUTONOMIA), and changes in the compositions of secretions.
Sicca can affect many parts of the body, including the eyes, mouth, nose, airways, sinuses, gastrointestinal (GI) tract, skin, and vagina. Non-rheumatology specialists typically manage the symptoms of sicca that occur in the GI tract, skin, and genitals.
Every Sjogren’s patient needs care for both sicca and non-sicca (systemic) Sjogren’s features.
Patients who do not have sicca early on usually develop it. Eye damage can occur even when patients don't feel dry. This is why every patient should have routine eye checkups regardless of symptoms. Without adequate eye care, permanent damage, visual impairment, or even blindness may occur. Without adequate dental care, patients may develop severe tooth decay and sometimes loose their teeth.
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Sicca is Overemphasized in Sjogren's.
Sicca symptoms are NOT the reason that most people seek a Sjogren's diagnosis.
However, because some doctors are still wrongly taught that sicca is the main feature of the disease, they may not recognize typical early signs and symptoms of Sjogren's. Patients often consult eye doctors and dentists for sicca-related problems, unaware that these issues could be warning signs of a systemic disease.
Common reasons people seek a diagnosis of Sjogren's include:
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profound fatigue, cognitive impairment, joint and muscle pain (often misdiagnosed as fibromyalgia)
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exercise intolerance
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gastrointestinal problems
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neuropathy and dysautonomia symptoms
See PCP STEPS TO DIAGNOSIS to learn more about the many ways Sjogren's can present.
Most people are diagnosed with Sjogren's after sicca has far progressed.
It takes years for damage to build up enough to produce obvious or measurable dryness. Even when sicca symptoms are bothersome, most people don't think to mention sicca symptoms to their PCPs (234), because they think they are unimportant or unrelated to their systemic symptoms.
Not everyone with Sjogren’s has sicca, and not everyone with sicca has Sjogren’s. Sjogren’s is always systemic, even in patients who have sicca-dominant disease.
See WHAT IS SJOGREN'S? for more informaton.
About 1 in 5 people with Sjogren’s present with systemic (non-sicca) features and no obvious dryness (3, 8, 232). For most patients, sicca symptoms help point to a Sjogren’s diagnosis. Even though sicca is often the most obvious and visible feature of Sjogren's, most patients identify fatigue and pain as their most burdensome symptoms (169). Fatigue and pain are systemic features or the disease, not part of a "sicca syndrome".
​​BACK TO KEY CONCEPTS
Sicca is just one of many Sjogren's features.
Sicca is present in most, but not all, Sjogren's patients.
It is important to monitor and manage sicca, even when symptoms are mild.
Resources for Managing Sicca in Sjogren's
Sjogren’s Foundation Resources On Sicca
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National Patient Conference Recordings - Excellent presentations about sicca.
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Sjogren’s Clinical Practice Guidelines, Oral - Share these guidelines with your dentist.
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Sjogren’s Clinical Practice Guidelines, Ocular (eye) - Share these guidelines with your eye doctors. Note: The Ocular Guidelines do not include some of the newest prescription treatments.
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Brochures and Resource Sheets - Information on a variety of topics including dry eyes and dry mouth
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Other Resources On Sicca
The Sjogren’s Book (214) - ​See the Citations page for information about this book.
Sjogren’s Syndrome: A Clinical Handbook (151) - ​See the Citations page for information about this book.
Smart Patients - ​The Sjogren's patient group is a great online support group for practical tips
Dry Eye Disease (Ocular Sicca) Caused By Sjogren's
On average, it takes 10 years from a diagnosis of ocular (eye) sicca to a diagnosis of Sjogren’s (69). About 10% of ocular sicca patients have Sjogren’s. Eye doctors often treat ocular sicca without considering Sjogren’s as a possible cause, “Screening for SS (Sjogren’s) by ophthalmologists caring for patients with dry eye is not common practice, partly because serious ocular complications secondary to SS are not widely recognized.” (35)
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Time to Sjogren’s diagnosis could be improved if eye doctors asked about systemic (non-sicca) symptoms in ocular (eye) sicca patients. Likewise, other clinicians should ask about about ocular sicca symptoms in patients with common systemic features.
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Because Sjogren's eye sicca may not be interpreted by the patient as dryness, clinicians should ask about the symptoms listed in the blue box below if patients answer "no" to when asked about dry eyes.
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Every Sjogren’s patient should be monitored by an eye doctor who is familiar with Sjogren’s eye disease at least once a year. The eye specialist is often an ophthalmologist (MD eye doctor) because patients taking hydroxychloroquine (HCQ) need to undergo routine retinal screening. An optometrist is often a good choice for managing dryness but they will need to refer to an ophthalmologist for HCQ screening or if signs and symptoms of systemic (non-sicca) eye disease occur, such as sudden onset of severe eye pain, vision changes, or sensitivity to light.
Ocular sicca symptoms are usually caused by a loss of tear volume, meibomian gland disease, and neuropathy. The meibomian glands secrete lipids that stabilize the eye surface. This keeps tears from evaporating quickly. Many patients need to treat both aspects of dry eye disease.
This Sjogren's Foundation blog post explains how autonomic dysfunction and sensory neuropathy contribute to dry eye disease symptoms.
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People with Sjogren's may have decreased functional vision even if they have normal vision based on reading a standard eye chart. Blurring, difficulty reading, difficulty looking at a TV, computer, or smartphone screen, and poor night vision may be caused by a disrupted tear film.
Ocular sicca may cause serious damage. Sicca caused by Sjogren's is often more damaging than sicca not caused by Sjogren's. People with mild sicca symptoms caused by Sjogren's may be accruing serious damage (235). Ocular sicca caused by Sjogren's is not trivial; when ignored it can lead to corneal ulcers, altered vision, or even blindness (69).
Not all eye diseases caused by Sjogren’s are related to dryness. Systemic (non-sicca) eye manifestations such as uveitis, scleritis, and corneal melt may occur (69, 156). These vision-threatening emergencies require urgent treatment. Sudden onset of eye pain, vision changes, and redness may indicate one of these conditions.
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Symptoms of Ocular (Eye) Sicca
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Dryness/inability to produce tears
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Eye irritation, pain, or burning
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Blurry vision, needing to blink to correct vision
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Redness, sensitivity to light, poor night vision
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A gritty feeling or foreign body sensation in the eyes
Note: It is safe to assume that people who use prescription treatments for dry eye (Restasis, Cequa, Xiidra, etc.) or artificial tears more than two times a day have sicca.
Dry Mouth (Oral Sicca) Caused By Sjogren's
When not managed aggressively, oral sicca may lead to severe dental decay (caries) or even loss of teeth. People with Sjogren's often do not mention oral health concerns to anyone other than their dentist. Primary care clinicians and others should ask about eye and oral sicca any time that a patient presents with systemic symptoms that could be caused by Sjogren’s.
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Because oral sicca may feel normal to the patient, clinicians should ask about a variety of sicca symptoms if they answer "no" when asked about dry mouth.
Symptoms Of Oral Sicca Caused By Sjogren's
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Dry mouth sensation
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Difficulty swallowing food without liquids
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Problems with food or pills getting stuck
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Severe, unexplained caries despite good oral hygiene
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Burning, irritated tongue and mouth
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Recurrent candida infections (thrush) and angular cheilitis
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Heartburn [gastroesophageal reflux disease (GERD)]
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Difficulty tasting food
Sjogren’s patients may develop severe caries despite practicing good dental hygiene.
Dental caries do not occur in proportion to measured saliva flow. Other factors such as microbiota, lack of mucin secretion, and inflammatory changes contribute to dental decay and sometimes loss of teeth.
Oral candidiasis and angular cheilitis
Oral candidiasis (thrush) often causes bright red mucous membranes, rather than the typical “cottage cheese” appearing film in the mouth. These conditions often require 10-14 days of treatment with antifungal medication.
Burning mouth and tongue
Burning mouth and burning tongue have multiple causes including candidiasis, neuropathy, nutritional deficiencies, and more. Salivary gland blockages (by stones or mucus) and infections may contribute to this and often require treatment by an ear, nose, and throat (ENT) doctor (151, Ch. 3).
Oral sicca contributes to gastroesophageal reflux disease (GERD) (148).
GERD is more likely with oral sicca because saliva buffers stomach acid and loosens mucus. GERD may cause chronic cough. Any Sjogren’s patient with a chronic cough should be evaluated for lung disease.
Difficulty swallowing (dysphagia) may be caused by dryness, autonomic neuropathy, or both (148).
Loss of taste and smell may occur.
This, combined with impaired swallowing often lowers the quality of diet and may result in weight loss and lower quality of life.
Dysautonomia and sensory neuropathy may contribute
to ocular and oral sicca symptoms.
Saliva and tear glands are directly damaged by Sjogren’s.
However, the loss of function frequently does not match the amount of damage.
Severe oral dryness has been documented with only a 50% loss of glandular structure, which should be enough to make adequate saliva (233). This data suggests that the autonomic nervous system, which stimulates saliva and tear production, may play an important role in sicca.
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Dysautonomia and small fiber neuropathy may contribute to many Sjogren's
features, including sicca.
Sicca of the Airways Caused by Sjogren's
The moist mucous membranes that line the nose, sinus, and airways provide the first line of defense against respiratory infections. Dryness and inflammation disrupt this important part of the innate immune system. This is part of the reason that Sjogren’s patients tend to experience severe or repeated respiratory infections (39).
People with Sjogren’s may experience recurrent sinusitis, sometimes starting many years prior to diagnosis.
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Chronic cough, productive or non-productive, may be the first sign of Sjogren’s disease (79).
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Any patient with chronic cough should be evaluated for Sjogren’s lung disease according to the Pulmonary Clinical Practice Guidelines (159). Sjogren’s lung disease is common and underdiagnosed. Chronic cough should not be attributed to dryness until lung disease, GERD, and/or laryngopharyngeal reflux (LPR) have been ruled out.
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Damage to the mucosal surfaces of the airways can led to bronchiectasis, which is made worse by dryness of the mucus secreting glands.
Bronchiectasis is a dilation and inflammation of the medium sized airways. It may contribute to compromised lung function and/or pneumonia (214, Ch. 28). Bronchiectasis and other Sjogren’s airway diseases are sometimes misdiagnosed as asthma/ bronchitis.
Skin and vaginal sicca are also common in Sjogren's.
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Updated 09-13-2025