Raynaud’s

Definition/diagnostic criteria Raynaud’s phenomenon is characterized by episodic vasospasm and ischemia of the extremities, primarily affecting the fingers and toes. It can be classified into two types: primary Raynaud’s (Raynaud’s disease) and secondary Raynaud’s (Raynaud’s phenomenon). Primary Raynaud’s is idiopathic, whereas secondary Raynaud’s is associated with other diseases, particularly connective tissue diseases. The diagnosis is primarily clinical, based on the patient’s history and the presence of characteristic colour changes (white, blue, and red) in the extremities, usually triggered by cold or emotional stress.

Epidemiology Raynaud’s phenomenon is relatively common, with a higher prevalence in colder climates. In the UK, it is estimated that up to 10% of the population may be affected, with women more commonly affected than men. The condition typically presents between the ages of 20 and 40. Secondary Raynaud’s is less common than primary Raynaud’s but is more likely to be associated with significant morbidity.

Diagnosis

Clinical Features The diagnosis of Raynaud’s is primarily clinical. Patients typically present with episodic attacks of colour change in the fingers and toes, often in response to cold or emotional stress. The colour change follows a characteristic pattern: pallor (white) due to vasospasm, followed by cyanosis (blue) due to deoxygenation, and finally reactive hyperaemia (red) as the attack resolves. The attacks can be associated with pain, paraesthesia, and in severe cases, ulceration or sores at the fingertips.

Investigations While the diagnosis of Raynaud’s is mainly clinical, investigations may be required to differentiate primary from secondary Raynaud’s and to identify any associated conditions. Abnormal nailfold capillaries (as seen through a dermatoscope) suggest secondary Raynaud’s. Blood tests, including antinuclear antibodies (ANA) can help identify associated connective tissue diseases. Individuals with suspected secondary Raynaud’s or severe/rapidly progressing disease should be referred to a specialist.

Treatment Management of Raynaud’s phenomenon involves both non-pharmacological and pharmacological strategies. Non-pharmacological measures include keeping warm, stopping smoking, and managing stress. Calcium channel blockers, such as nifedipine, are considered the first-line pharmacological treatment and have been shown to reduce the frequency and severity of attacks. In cases where calcium channel blockers are contraindicated or not tolerated, some evidence suggests that losartan or sildenafil may be beneficial. For patients with secondary Raynaud’s or those with severe or refractory symptoms, referral to a specialist for further management and assessment of underlying conditions is recommended.

Prognosis The prognosis of Raynaud’s phenomenon varies depending on the subtype and presence of associated conditions. Primary Raynaud’s generally has a benign course, although it can impact quality of life. Secondary Raynaud’s can be associated with significant morbidity, depending on the nature and severity of the underlying condition. Early identification and management of associated conditions can improve outcomes in secondary Raynaud’s.