Raynaud’s phenomenon

Published on 02/04/2015 by admin

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Last modified 22/04/2025

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161 Raynaud’s phenomenon

Instruction

Examine this patient’s hands.

Salient features

History

• Ask the patient about the following:

• Whether precipitated by cold, emotion and relieved by heat
• The different phases change: in idiopathic Raynaud’s disease, the cold dead-white hands (ischaemia) become blue (stasis) and finally red (reactive hyperaemia) and painful
• Sensory changes secondary to vasospasm (numbness, stiffness, aching pain)
• Occupation (polishing tools, vibrating tools)
• Dysphagia (CREST syndrome)
• Butterfly rash, arthralgia, xerostomia (SLE, collagen vascular disorder)
• Use of electrically heated gloves.

Examination

• Hands may be painful: ask the patient.

• The hands and fingers are cyanosed and cold, or may be warm and red or blue (Fig. 161.1). The thumbs are rarely affected.

image

Fig. 161.1 Scleroderma showing Raynaud’s phenomenon: pallor, cyanosis, and often rubor of the skin, in response to cold or emotional stimuli.

Proceed as follows:

• Examine the hands carefully for signs of scleroderma (tightening of skin, telangiectasia).

• Examine the face for tightening of skin around the mouth (scleroderma), butterfly rash (SLE).

• Tell the examiner that you would like to examine upper limb pulses and BP in both upper limbs (useful in the detection of cervical rib).

Diagnosis

This patient has cold, blue hands (lesion) caused by Raynaud’s phenomenon (aetiology) and is unable to continue her occupation, which requires using a vibratory hand drill (functional status).

Advanced-level questions

How is primary Raynaud’s differentiated from secondary Raynaud’s phenomenon?

• Primary:

• Attacks are symmetric
• No tissue necrosis, ulceration, or gangrene
• No secondary cause on the basis of a patient’s history and general physical examination
• Normal nailfold capillaries
• Negative result when tested for anti-nuclear antibody
• Normal ESR.

• Secondary:

• Age at onset of >30 years
• Episodes are intense, painful, asymmetric, or associated with ischaemic skin lesions
• Clinical features suggestive of a connective-tissue disease (e.g. arthritis and abnormal lung function)
• Specific autoantibodies
• Evidence of microvascular disease on microscopy of nailfold capillaries.

What are the causes of Raynaud’s phenomenon?

• Immunological and connective tissue disorders:

• Scleroderma
• SLE
• Dermatomyositis
• Rheumatoid arthritis.
• Mixed connective tissue disorders.

• Obliterative arterial disease:

• Atherosclerosis
• Thoracic outlet syndrome, cervical rib.

• Occupational:

• Vibration, causing white fingers
• Cold injury, e.g. from handling frozen commodities
• Vinyl chloride.

• Drugs:

• Beta-blockers
• Bromocriptine
• Sulphasalazine
• Ergot alkaloids.
• Combination of bleomycin and vincristine (as for testicular cancer).

• Miscellaneous:

• Cold agglutinins
• Cryoglobulins
• Idiopathic.

Note: Raynaud’s disease is diagnosed if the phenomenon persists for greater than 3 years without evidence of associated disease.

What investigations would you do to look for autoimmune rheumatic disease in a patient with Raynaud’s phenomenon?

• FBC, ESR

• Total immunoglobulin and electrophoresis strip

• Urine analysis

• Nail-fold capillaroscopy

• Chest radiography

• Renal and liver function tests

• Test for anti-nuclear antibody

• Helicobacter pylori (one paper suggested that eradication of H. pylori ameliorates Raynaud’s phenomenon; Dig Dis Sci 1998;43:1641)

• Hand radiography.

What drugs have been used to treat Raynaud syndrome?

Nifedipine, nitrates, stanazolol, inositol nicotinate, naftidrofuryl oxalate, prostaglandin 12, thymoxamine, guanethidine, prazosin.

What is the role of surgery in treating Raynaud’s disease?

In patients resistant to medical therapy with severe, frequent attacks and if trophic changes have occurred interfering with work, dorsal sympathectomy may be indicated.

Do you know of any other vasospastic conditions?

• White finger syndrome

• Livedo reticularis

• Erythromelalgia

• Chilblains.

Further reading

Raynaud M. Selected monographs, vol 121, On local and symmetrical gangrene of the extremities (Barlow T trans). London: New Sydenham Society; 1888.

Auguste-Maurice Raynaud (1834–1881) described the sign in 1862. He was a physician at Hôpital Lariboisière, Paris. He died from an attack of angina pectoris.

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161 Raynaud’s phenomenon

Instruction

Examine this patient’s hands.

Salient features

History

• Ask the patient about the following:

• Whether precipitated by cold, emotion and relieved by heat
• The different phases change: in idiopathic Raynaud’s disease, the cold dead-white hands (ischaemia) become blue (stasis) and finally red (reactive hyperaemia) and painful
• Sensory changes secondary to vasospasm (numbness, stiffness, aching pain)
• Occupation (polishing tools, vibrating tools)
• Dysphagia (CREST syndrome)
• Butterfly rash, arthralgia, xerostomia (SLE, collagen vascular disorder)
• Use of electrically heated gloves.

Examination

• Hands may be painful: ask the patient.

• The hands and fingers are cyanosed and cold, or may be warm and red or blue (Fig. 161.1). The thumbs are rarely affected.

image

Fig. 161.1 Scleroderma showing Raynaud’s phenomenon: pallor, cyanosis, and often rubor of the skin, in response to cold or emotional stimuli.

Proceed as follows:

• Examine the hands carefully for signs of scleroderma (tightening of skin, telangiectasia).

• Examine the face for tightening of skin around the mouth (scleroderma), butterfly rash (SLE).

• Tell the examiner that you would like to examine upper limb pulses and BP in both upper limbs (useful in the detection of cervical rib).

Diagnosis

This patient has cold, blue hands (lesion) caused by Raynaud’s phenomenon (aetiology) and is unable to continue her occupation, which requires using a vibratory hand drill (functional status).

Advanced-level questions

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