Raynaud’s
phenomenon
When is it serious?
Neil McHugh
Bath Clinic June 2011
Raynaud’s phenomenon
Maurice Raynaud (1834 – 1881)
De l'asphyxie locale et de la
gangrène symétrique des
extrémités.
Doctoral thesis, published
February 25, 1862.
Clinical features or Raynaud’s
 Primarily affects fingers
 Can affect toes, thumbs,
nipples, nose, earlobes
 Episodes precipitated by
cold exposure and
emotional stress
 Episodes accompanied by
pain +/- numbness
 Pulses present
 Necrosis / tissue damage
suggestive of secondary
cause
Initial ischaemia
Pallor
Cyanotic phase
Blue
Hyperaemic phase
Red / purple
Definition of RP
 Definite
repetitive episodes of biphasic
colour change (at least 2 of
pallor, cyanosis, erythema), in
either cold or normal
environment
Pathogenesis
Causes
 Primary (~10-15% of healthy population, female
predominance)
 Secondary
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Drugs e.g. Beta blockers
Connective tissue disorders e.g. systemic sclerosis
Eating disorders
Haematological e.g. cold agglutinins
Vascular occlusion e.g. vasculitis, thoracic outlet
obstruction, Buerger’s disease
 Occupation e.g. vibrating tool use
 Others e.g. hypothyroidism, carpal tunnel syndrome
Is it seconday Raynaud’s?
 History
 Severity, age of onset, gender,
symptoms of CTD etc
 Clinical examination
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Radial pulses
Skin changes
Nailfold changes
Joint disease
Carpal Tunnel Syndrome
 Laboratory investigations
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FBC, U&E, LFT, CRP, TSH
Autoimmune profile
Nailfold capillaroscopy
Infrared thermography
Systemic sclerosis
Laser Speckle Contrast
Imaging
Healthy control
Systemic sclerosis
Management
 General measures
 Raynaud’s and Scleroderma Association
 www.raynauds.org.uk
 Scleroderma Society
 Sclerodermasociety.co.uk
 Arthritis Research UK (formerly ARC)
 www.arthritisresearchuk.org
 Maintenance of core temperature
 Avoidance of cold exposure
 Cessation of vasoconstrictive Rx e.g. B blockers
 Gloves (heated)
 Smoking cessation
Promoting vasodilation
 Calcium channel blockers
 Dihydropyridine
 Nifedipine better than amlodipine
 Nitrates
 Transdermal or oral
 Prostaglandins
 IV (disappointing results with oral preparation)
 Phosphodiesterase V inhibitors
 Under investigation. Remain expensive.
Preventing vasoconstriction
 ACEi and ARBs
 e.g. losartan
 May be better in primary RP
 Alpha adrenoceptor blockade
 e.g. prazosin
 SSRIs
 e.g. fluoxetine
 May be better in primary Raynaud’s
 Endothelin receptor antagonists
 e.g. bosentan
 Reserved for use in CTD
Novel treatments
 Rho kinase inhibitors
 Responsible for cold-induced expression of alpha2 adrenoceptors
 Statins
 In part due to Rho kinase inhibition
 Antiplatelet treatments?
 Current trial at RNHRD (for primary and
secondary Raynaud’s)