Raynaud’s Phenomenon: Causes and Treatment

Raynaud phenomenon (RP) is a condition in which exposure to cold temperature or emotional stress induces a change in the color of the fingers and toes. It occurs because of an exaggerated constriction of the blood vessels in the hands and feet in response to cold or stress. The prevalence of RP ranges from 10 to 20% in the population with higher rates in women.

Classification of Raynaud’s Phenomenon

• Primary RP: In this type, the symptoms of RP occur alone without any other systemic disease
• Secondary RP: This type is associated with an underlying disease or other cause
• Autoimmune diseases like Systemic Lupus Erythematosus (SLE), Scleroderma, Sjogren’s syndrome, Polymyositis/Dermatomyositis.
• Drugs that cause constriction of the blood vessels like amphetamines, anti-migraine medications, and smoking cigarettes.
• Repeated trauma and use of vibration devices and tools

Symptoms of Raynaud’s Phenomenon

The symptoms are usually noted in the hands occurring in response to cold or emotional stress.

Typically, there are three phases of color changes lasting 15 to 20 minutes

• White or skin pallor: The fingers appear pale beyond a sharply demarcated line. This occurs due to constriction of the blood vessels in response to cold
• Blue or cyanotic skin: The lack of oxygen supply to the tissues leads to the bluish discoloration which occurs next
• Red or erythema: The vessels dilate and the rush of blood back into the fingers is noted as a red flush.

The other symptoms are

• Cold sensation of the hands and toes
• Pins and needles with some pain
• A mottled, lacy rash over the hands called livedo reticularis

Diagnosis of Raynaud’s Phenomenon

The diagnosis is made clinically based on the history of classic symptoms. A secondary cause for RP is evaluated through the following

• Physical Exam: The presence of a fever, rash, joint pains, skin changes may indicate an underlying autoimmune disease
• Nail fold capillary microscopy: The pattern of blood vessel loops in the nail fold visualized under a microscope can distinguish between primary and secondary RP
• Blood investigations: Specific lab test for autoimmune conditions can be used to screen for an underlying disease

Treatment of Raynaud’s Phenomenon

Initial steps to manage RP involves general precautions

• Preventing exposure to cold, especially sudden changes in temperature. Dressing warmly and protecting the hands and feet from the cold is important.
• Avoiding drugs that can trigger constriction of the blood vessels.
• Avoiding smoking cigarettes
• Stopping the use of tolls that vibrate
• Reducing emotional stress

If these general measures do not help in controlling RP, medications may be tried

• Calcium channel blockers (CCBs): These are the first line of therapy in RP. The recommended CCBs are nifedipine and amlodipine
• Other blood vessel dilators like sildenafil and locally applied nitrates can be tried.
• Surgery: In very severe cases, surgical correction of the blood vessels may be required.

Prognosis of Raynaud’s Phenomenon

Primary RP is generally mild and often goes away on its own with time. Secondary RP on the other hand tends to be more severe, with repeated episodes not responding to therapy and may lead to ulcers and gangrene of the fingers due to a complete stop in blood flow. The underlying condition may also progress rapidly making things worse.

References:

• Silman A, Holligan S, Brennan P, Maddison P. Prevalence of symptoms of Raynaud’s phenomenon in general practice. BMJ. 1990 Sep 22;301(6752):590–2.
• Nancy Garrick DD. Raynaud’s Phenomenon [Internet]. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2017 [cited 2018 May 25].