Raynaud's phenomenon

Episodic vasospasm of small arteries (usually in the fingers/toes) triggered by cold or stress, causing transient color changes (white → blue → red) and numbness/pain. It occurs in a primary (idiopathic) form and secondary form associated with underlying diseases.

• Common (~3–5% prevalence) and usually benign, especially in young women. However, secondary Raynaud's can be a harbinger of serious autoimmune diseases (e.g., systemic sclerosis), so recognizing the classic color changes can prompt early diagnosis. Frequently tested on exams as a classic vascular phenomenon.

• Episodes classically follow a triphasic color change: affected digits turn white (ischemia), then blue (cyanosis), then red upon rewarming (reactive hyperemia). Patients often report cold-induced numbness or tingling pain in fingers or toes, with spontaneous relief on warming.
• Primary Raynaud's (Raynaud disease) typically affects young women (onset in teens/20s) with symmetric attacks and no tissue damage. Secondary Raynaud's tends to start later (>30 years), may be asymmetric and more painful, with complications like fingertip ulcers or gangrene. Common secondary causes include connective tissue diseases (especially scleroderma, lupus), arterial occlusive disease, repeated vibrational trauma, or certain drugs.
• Between attacks, exam is usually normal in primary Raynaud's. In secondary forms, there may be signs of the underlying condition (e.g., sclerodactyly or calcinosis in scleroderma). Nailfold capillaroscopy (examining capillaries at the fingernail bed) is often normal in primary RP but shows abnormal dilated or drop-out capillaries in many secondary cases (a key clue for scleroderma).

1. Determine if primary vs secondary: look for red flags such as onset after 30, male sex, asymmetric or painful attacks, or digital ulcers → suggest secondary Raynaud's. If suspected, evaluate for underlying diseases (check ANA and other autoantibodies, perform nailfold capillaroscopy, etc.).
2. Advise lifestyle measures for all patients: keep extremities warm (gloves, warm socks), avoid sudden cold exposure (even freezer sections), manage stress, and stop smoking or any vasoconstricting medications.
3. For primary Raynaud's with frequent attacks, start a dihydropyridine CCB (e.g., nifedipine) to reduce vasospasm. If attacks are mild/infrequent, conservative management may suffice.
4. For secondary Raynaud's, treat the underlying disorder (e.g., immunosuppressives for lupus or sclerosis, address hypothyroid, etc.) and use medication more aggressively. Options (often off-label) include CCBs, topical nitroglycerin, PDE-5 inhibitors like sildenafil, or prostacyclin analogs (IV iloprost) for severe cases.
5. Refer to a rheumatologist for secondary cases or if autoimmune labs (ANA, etc.) are positive. If there are severe ischemic complications (non-healing ulcers or gangrene), involve a vascular specialist; treatments like IV prostaglandins, bosentan (endothelin blocker), or even sympathectomy may be considered in refractory cases.

1. Lifestyle: First-line for all – keep body and extremities warm (wear gloves, layered clothing), avoid sudden cold exposure, manage stress, and avoid smoking/nicotine.
2. Pharmacologic: If attacks are frequent or severe, use calcium channel blockers (e.g., nifedipine or amlodipine) to reduce vasospasm. Alternatives or add-ons include topical nitroglycerin paste for local areas, PDE-5 inhibitors (sildenafil) for severe cases, or angiotensin receptor blockers; in extreme cases IV prostacyclin (iloprost) may be used.
3. Secondary RP management: Treat the underlying condition (e.g., immunotherapy for lupus/scleroderma). Refer to specialists as needed. For critical digital ischemia (ulcers/gangrene), inpatient treatment with IV vasodilators, bosentan (to prevent new ulcers in scleroderma), or even surgical sympathectomy can be considered.

• Remember the color sequence: White → Blue → Red ("white" from lack of blood flow, "blue" from deoxygenation, "red" from reperfusion). Exams often describe this triphasic change in a cold-exposed hand.
• Beta-blockers and other vasoconstrictive drugs (e.g., some migraine meds, stimulants) can worsen Raynaud's – consider this if symptoms start after a new medication.
• In a patient with known scleroderma (systemic sclerosis), new-onset severe Raynaud's with fingertip ulcers indicates active disease – requires aggressive therapy to prevent digital gangrene.

• Onset of Raynaud's after age 30, male patient, or unilateral/asymmetric attacks → suspect secondary cause (requires workup for autoimmune or vascular disease).
• Any ulcers, pitting scars, or signs of tissue injury on fingertips → indicates severe secondary Raynaud's (urgent aggressive treatment to prevent permanent damage).
• If ANA or other autoimmune markers are positive in a Raynaud's patient, monitor closely for development of a connective tissue disease (e.g., systemic lupus or scleroderma).

1. Recurrent finger color changes (white/blue ± red) triggered by cold → suspect Raynaud's phenomenon.
2. Evaluate red flags: age >30 at onset, asymmetry, painful ulcers? If yes → work up for secondary causes (labs like ANA, nailfold capillaroscopy, vascular studies).
3. No secondary signs → likely primary Raynaud's: educate on avoidance of triggers and observe. Add medical therapy (e.g., nifedipine) if needed for symptom control.
4. Secondary Raynaud's confirmed or strongly suspected → manage underlying disease (e.g., rheumatologic referral) and initiate vasodilator therapy (CCB first-line, others as needed).
5. Severe ischemia (digital ulceration or gangrene risk) → consider advanced therapies (IV prostacyclin, sympathectomy in refractory cases) and involve specialist care.

• A 20‑year‑old woman in winter finds her fingers turning white then blue when cold, with numbness that resolves on warming. No other symptoms or exam findings. → Primary Raynaud's phenomenon (manage with warming and nifedipine as needed).
• A 45‑year‑old woman with tight skin on her hands (sclerodactyly) and telangiectasias has episodes of painful finger pallor in cold and a non-healing fingertip ulcer. ANA is positive. → Secondary Raynaud's due to systemic sclerosis (CREST syndrome). Requires vasodilator therapy and rheumatology management.
• A manual laborer who operates vibrating tools and smokes heavily develops Raynaud's phenomenon in his fingers. → Likely secondary Raynaud's (vibration-induced vascular damage + smoking). Emphasize smoking cessation and protective equipment; treat with CCBs.