Raynaud’s Phenomenon

Raynaud’s phenomenon (also known as Raynaud’s) is a condition where the fingers and/or toes undergo colour changes on exposure to the cold environment or emotional stress. Other areas may also be affected, such as the ears, nose, lips or tongue. These triggers lead to an exaggerated constriction (narrowing) of the small blood vessels supplying these areas in people with Raynaud’s. This results in reduced blood flow to the affected areas leading to colour changes, characteristically white followed by blue then red. Not everyone has all three colour changes. When they do occur, each colour represents a different phase of blood flow in the affected areas:

• White – reduced blood flow as the blood vessels narrows
• Blue – reduced oxygen levels in the affected digits
• Red – increased blood flow as circulation returns to the affected digits
  

There can also be pain, tingling, numbness, throbbing sensation in the affected areas during an attack of Raynaud’s.

There are two main types of Raynaud’s:
• Primary Raynaud’s – occurs on its own without any underlying condition. This condition often starts in early adulthood and is usually mild.
• Secondary Raynaud’s – associated with an underlying condition, often a connective tissue disease. It is more likely to be associated with complications such as skin ulcers or gangrene (blackening of the digits).

An estimated 1 in 20 individuals have Raynaud’s phenomenon, and it is more common in women. Primary Raynaud’s is much more common than secondary Raynaud’s.

Raynaud’s phenomenon happens because of an exaggerated narrowing of the small blood vessels in the fingers or toes in response to the cold or emotional stress. 

For primary Raynaud’s, the exact cause is unknown. Genetic factors may play a role, as it can run in families. 

For secondary Raynaud’s, an underlying disease is present, most commonly an autoimmune condition such as
• Systemic sclerosis 
• Systemic lupus erythematosus
• Sjogren’s syndrome 
• Dermatomyositis 
• Mixed connective tissue disease

Secondary Raynaud’s may also develop in people who use repetitive vibratory hand tools for prolonged periods, local trauma or certain medications e.g. beta blockers, nasal decongestants, certain migraine and attention deficit hyperactivity disorder (ADHD) medications.

Raynaud’s phenomenon is diagnosed clinically based on history and physical examination. A comprehensive evaluation will include assessing for any complications of Raynaud’s, screening for secondary causes, taking a family history, occupational history and medication history.

Additional tests may be conducted if there is suspicion of secondary causes, these may include:
• Blood tests to evaluate the major organ functions and inflammatory markers
• Antibody tests such as the anti-nuclear antibody and more specific antibodies depending on clinical suspicion
• Urine tests to assess for any potential kidney involvement
• Nailfold capillaroscopy: a simple test where a doctor looks at the small blood vessels at the base of the fingernails under a microscope. Patients with certain autoimmune conditions may have abnormal blood vessels around the fingernails

Lifestyle measures are the mainstay for both primary and secondary Raynaud’s.
• Keep the whole body warm – Wear layered clothing, gloves and socks. 
• Avoid rapidly shifting temperatures such as rushing into an air-conditioned area.
• Rubbing hands with chemical warmers or warm water can help to improve circulation to the fingers and speed up resolution of Raynaud’s.
• Avoid smoking.
• Managing stress.
• Review your medications with your care provider as some medications may trigger Raynaud’s, such as beta blockers, nasal decongestants, certain migraine and ADHD medications. 
• Avoid repetitive use of vibratory tools.

For patients with moderate to severe Raynaud’s, medications (vasodilators) may be started to improve blood flow to the limbs to reduce Raynaud’s attacks and prevent finger ulcers. Examples include calcium channel blockers (e.g. amlodipine, nifedipine), phosphodiesterase 5 inhibitors (e.g. sildenafil, tadalafil) and endothelin receptor antagonists (e.g. bosentan). Intravenous (injection medications given through the veins) vasodilators (prostacyclin analogue) may be given in patients with secondary Raynaud’s who experience refractory symptoms. 

In patients who develop skin ulcers or gangrene, careful wound management and appropriate pain relief are an important part of treatment. Additionally, patients with secondary Raynaud’s will need to have their underlying autoimmune disease treated holistically by a rheumatologist.

Seek a Family Physician’s advice. Primary Raynaud’s phenomenon is common, benign and can be managed with lifestyle changes. You will be referred to a specialist (rheumatologist) if there is a suspicion of an underlying rheumatic disease associated with Raynaud’s phenomenon