Raynaud's Phenomenon

Related Subjects: |Relapsing Polychondritis |Reactive Arthritis |Raynaud's Phenomenon

Clues that may raise concern for secondary Raynaud's include age of onset greater than age 40, male gender, digital ulcerations, asymmetric attacks, ischemic signs proximal to the fingers and toes, and abnormal nail fold capillaroscopy.

About

• Spasm of distal arteries to the fingers and toes

Classification

• Primary : usually affects young women and teenage girls. Primary Raynaud's is generally considered a benign condition
• Secondary: usually to another often connective tissue disease. Prognosis is related to the underlying cause
  • Connective tissue disorders: Scleroderma, Systemic sclerosis, SLE, RA, dermatomyositis or polymyositis.
  • Occupational: Using vibrating tools.
  • Vascular Obstructions: Thoracic outlet obstruction, Buergers disease, atheroma.
  • Haem: Thrombocytosis, cold agglutinin disease, PRV, monoclonal gammopathies.
  • Drugs: Beta-blockers.
  • Hypothyroidism
  • Others : polyvinyl chloride exposure, and cryoglobulinemia.

Aetiology

• Imbalance of neural vasoconstriction response
• Excess vasoconstrictors
• Deficit of vasodilators e.g. Nitric oxide
• High plasma viscosity

History

• French physician, Maurice Raynaud, who first described it. 1862

Epidemiology

• Raynaud's may be present in 5-20% of women and in 4-14% of men.

Diagnostic criteria for primary Raynaud phenomenon

• Attacks triggered by exposure to cold and/or stress
• Symmetric bilateral involvement
• Absence of necrosis
• Absence of a detectable underlying cause
• Normal capillaroscopy findings
• Normal laboratory findings for inflammation
• Absence of antinuclear factors

Clinical: Triphasic color change of the digits

• 1. Initial white or pallor (ischaemic phase)
• 2. Stasis and blue or cyanosis (deoxygenation phase)
• 3. Red or erythema (reperfusion phase). Often painful.
• Severe causes can have progressive digital gangrene and severe ischaemic changes
• Ask about rashes, joint pain, dry eyes, dry mouth suggesting secondary disease

Investigations

• FBC, U&E, LFTS, TFTS, ESR/CRP
• ANA, dsDNA, RF, ACP, Glucose
• CXR: Cervical rib may be compressing subclavian artery.
• Nailfold capillaroscopy is an inexpensive, quick, and non-invasive exam technique that can help differentiate primary from secondary Raynaud's. Lubricant is placed on the nail folds and the nailbed capillaries can be viewed using an ophthalmoscope set at 10 to 40 diopters. The fourth and fifth digits have the greatest translucency of the skin but all fingers should be visualized. Early abnormal findings will include few capillary haemorrhages and few enlarged capillaries. A more active pattern may show moderate loss of capillaries, frequent giant capillaries, and disorganized vascular architecture. A late pattern may show drop-out with severe loss of capillaries with extensive avascular areas and ramified or bushy capillaries. These abnormalities are found in patients with underlying connective tissue diseases such as systemic sclerosis, dermatomyositis, or undifferentiated connective tissue disease.

Management

• Keep warm - gloves - central body core warmth and not just peripheries
• Stop smoking and avoid sympathomimetics (cold remedies) and beta-blockers
• Regular exercise and manage stress
• Rheumatology referral if secondary disease suspected

Pharmacological

• Calcium channel blockers - acutely short-acting oral Nifedipine qds or slow-release or long-acting preparations of Nifedipine or Amlodipine. Most patients tolerate these well.
• Nitrates would probably be second line but there are many new medications being assessed
• Ketanserin, a selective antagonist of the S2-serotonergic receptor
• Angiotensin converting enzyme [ACE] inhibitor or ARB2 - reduces angiotensin II
• Infusion of CGRP has been evaluated as a possible therapy
• Sildenafil and other phosphodiesterase inhibitors
• Prazosin has been reported to improve RP
• Fluoxetine - SSRI
• Infusions of Prostacyclin (PGI2)
• Lumbar Sympathectomy for lower limb symptoms

References

• Managing Raynauds
• A Review of Raynaud's Disease