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During the winter months, complaints of pain associated with cold fingers and toes increase. In New Zealand, it is estimated
that 19% of females and 5% of males experience symptoms consistent with Raynaud’s phenomenon.1 This is
a circulatory disorder, characterised by episodic attacks where arteries in the fingers and toes spasm, restricting blood
flow and causing pain and marked colour changes of the skin.2 In some people it may also affect other peripheral
areas, such as the tip of the nose and ears.
In New Zealand, Raynaud’s phenomenon is reported to affect Māori and people with manual occupations more
severely.1 Initial vasoconstriction causes a white appearance to the skin as blood flow decreases, which is
often followed by a cyanotic blue phase, as the trapped blood deoxygenates.2 Attacks may last from minutes
to hours and usually end with rapid perfusion of blood back into the digits, which then appear red. Episodes of Raynaud’s
frequently cause pain and a “pins and needles” sensation due to sensory nerve ischaemia.2 The cause
of Raynaud’s is unknown, however, it is likely to involve increased activation of sympathetic nerves due to cold,
or emotional stimulus.2 In secondary Raynaud’s, abnormalities of vascular structure and function from
the underlying condition contribute to the phenomenon.
Diagnosis is based on clinical symptoms and signs
A diagnosis of Raynaud’s phenomenon is based on a history of repeated and sudden episodes with the characteristics
as described above. Patients may report attacks being triggered by cold weather, or other cold environments such as refrigerated
areas in supermarkets or from cold air conditioning.3 There may be a family history present. An occupational
history should be taken – people who use vibrating hand tools or have ongoing exposure to cold, e.g. meat packers, are
at an increased risk of Raynaud’s.3
Raynaud’s can be primary or secondary
It is important to distinguish between primary and secondary Raynaud’s so that a potentially serious, underlying
condition, is not overlooked. Primary Raynaud’s has no underlying etiology and clinical examination may be normal,
therefore it is a diagnosis of exclusion.
Secondary Raynaud’s can occur due to a number of connective tissue diseases such as systemic sclerosis (scleroderma),
systemic lupus erythematosus and rheumatoid arthritis, but can also occur with a range of other conditions, including
carpal tunnel syndrome and hypothyroidism. Raynaud’s may also be secondary to medicines or trauma, particularly
vibration injury.3 Patients with secondary Raynaud’s may have skin changes such as ulcerated or necrotic
patches around the affected area.4
The presence of any of the following factors suggest a diagnosis of secondary Raynaud’s:3
- Age of onset > 30 years
- Intense, painful, asymmetric attacks or attacks associated with ischaemic skin lesions
- Symptoms suggestive of an underlying disorder, especially a connective tissue disease – such as systemic sclerosis,
where in up to 90% of cases Raynaud’s is one of the presenting symptoms.5
Laboratory testing is unhelpful in people with primary Raynaud’s, but if a diagnosis of secondary Raynaud’s
is suspected, testing may help confirm the presence of an underlying condition. Initially, testing may include complete
blood count, CRP and antinuclear antibody (ANA), however, other tests may be indicated depending on the clinical findings
and suspected underlying condition. In some cases, treating the underlying condition will also ameliorate Raynaud’s
Conservative treatment is often the best
Behaviour modification is the first strategy for alleviating symptoms of Raynaud’s phenomenon. A “common
sense” strategy of avoiding abrupt changes in temperatures, therefore preventing peripheral vasoconstriction, can
be effective. Considerations include clothing, home heating and workplace conditions.
Practical tips for avoiding or minimising episodes of Raynaud’s include:7
- Keep the whole body warm and wear warm socks, gloves and a hat when going out in cold weather
- Avoid carrying objects in the hand, e.g. a handbag, which can restrict blood to the fingers when gripped
- Maintain regular movement, e.g. squeezing a stress ball or walking round the room
- Avoid smoking as this causes vasoconstriction
- The consumption of “warming” foods such as porridge or chilli has been reported by some people to ameliorate
- When an attack occurs, place hands in warm water or under the armpits, or rotate arms in a windmill pattern
People who experience Raynaud’s should avoid medicines which reduce blood flow to the peripheries, such as:4
- Serotonin receptor agonists, e.g triptans used to treat migraines
- Ergots (Claviceps fungi derivatives), e.g. ergotamine used to treat migraines
- Clonidine (which decreases cardiac output)
Historically there have been reports that non-selective beta-blockers, e.g. propanolol, carvedilol, nadolol, exacerbate
Raynaud’s. Recent studies have shown that beta blockers with beta-1 selectivity, e.g. metoprolol, are less likely
to cause vasoconstriction in patients with Raynaud’s. However, beta blockers should be used cautiously, in people
who experience severe Raynaud’s symptoms.8
Medication is the second option
In severe cases of Raynaud’s, the use of medicines that cause vasodilation of the digits may be considered. Calcium
channel antagonists such as nifedipine, amlodipine and felodipine are frequently effective in the treatment of Raynaud’s
and are all fully funded in New Zealand. However, calcium channel blockers are less effective for treating patients with
secondary Raynaud’s, notably Raynaud’s secondary to systemic sclerosis (sclerodoma).9
Adverse effects of treatment are experienced by up to three-quarters of patients with Raynaud’s and may include
headache, flushing, dizziness and peripheral oedema. However, these effects can be controlled with careful dosing and
if mild, are often considered by the patient to be preferable to the symptoms of Raynaud’s itself.9
|Table 1: Calcium channel blockers for Raynaud’s phenomenon9
||30 – 120 mg/day
||5 – 10 mg/day
|Felodipine (extended release)
||2.5 – 10 mg/day
It is recommended that patients are started on the lowest dose of the chosen medicine (Table 1). The dose can then
be increased incrementally as required and tolerated. If a patient reports that one calcium channel blocker is ineffective
then another can be trialled.9 Primary Raynaud’s may spontaneously remit, therefore treatment can be
stopped from time to time in order to confirm persistence.4 Some people report that intermittent use of the
medicine prior to exposure to cold weather is sufficient.
Patients with secondary Raynaud’s, who find calcium channel blockers ineffective, may benefit from the concomitant
administration of an additional vasodilator such as transdermal nitroglycerin.9
Many other medicines, such as other vasodilators, endothelin antagonists, phosphodiesterase-5 inhibitors, prostaglandin
derivatives, statins, botulinum toxin and N-acetyl-cysteine have been trialled in patients unresponsive to calcium channel
blockers, however, there is limited evidence as to their effectiveness.
Rarely, in severe cases, surgical destruction of sympathetic nerves (sympathectomy) may be required to alleviate symptoms.
- Purdie G, Harrison A, Purdie D. Prevalence of Raynaud’s phenomenon in the adult New Zealand population. N Z
Med J 2009, 122;1306,55-62.
- Cooke JP, Marshall JM. Mechanisms of Raynaud’s disease. Vasc Med 2005;10:293–307.
- Wigley FM. Clinical manifestations and diagnosis of the Raynaud phenomenon. UpToDate 2011. Available from: www.uptodate.com (Accessed
- Clinical Knowledge Summaries. Raynaud’s phenomenon – Management. Available from: www.cks.nhs.uk (Accessed
- Devulder J, Van Suijlekom H, van Dogen R, et al. Ischemic pain in the extremities and Raynaud’s phenomenon.
Pain Pract 2011;11(2):1-8.
- Kawald A, Burmester GR, Huscher D, et al. Low versus high-dose iloprost therapy over 21 days in patients with secondary
Raynaud’s phenomenon and systemic sclerosis: A randomized, open, single-centre study. J Rhematol 2008;35(9):1830-7.
- Wigley F. Nonpharmacologic therapy for the Raynaud phenomenon. UpToDate, 2010. Available from: www.uptodate.com (Accessed
- Podrid PJ. Major side effects of beta blockers. UpToDate 2010. Available from: www.uptodate.com (Accessed
- Wigley FM. Pharmacologic and surgical treatment of the Raynaud phenomenon. UpToDate 2011. Available from: www.uptodate.com (Accessed