Can Raynaud's phenomenon cause nail pitting and ridging?

Nail Pitting and Ridging in Raynaud's Phenomenon

Yes, Raynaud's phenomenon can cause nail pitting and ridging, particularly in cases of distal Candida nail infections which are strongly associated with underlying Raynaud's phenomenon. 1

Relationship Between Raynaud's and Nail Changes

Raynaud's phenomenon affects the microcirculation of the digits, which can lead to various nail abnormalities:

• Distal Candida nail infections: According to the British Association of Dermatologists' guidelines, distal nail infection with Candida is uncommon, and "nearly all patients with this condition suffer from Raynaud phenomenon or some other underlying vascular problem." 1

• Nail manifestations: When Candida affects the nails in patients with Raynaud's, the following changes can occur:

  • Transverse or longitudinal furrowing (ridging)
  • Pitting
  • Nail opacity
  • Friability of the nail
  • Potential detachment from the nail bed 1

Pathophysiological Mechanism

The connection between Raynaud's and nail changes involves:

1. Vascular insufficiency: Raynaud's causes episodic vasospasm of digital arteries, leading to reduced blood flow to the nail matrix and bed 2

2. Secondary infection: The compromised circulation creates an environment conducive to opportunistic infections, particularly Candida species 1

3. Structural changes: Chronic ischemia from Raynaud's can directly affect nail growth and structure, leading to ridging and other deformities 2

Clinical Presentation and Diagnosis

When evaluating nail changes in a patient with Raynaud's:

• Look for the classic triphasic color changes of Raynaud's (white, blue, and red phases) in the digits 2

• Examine nails for:

  • White, green, or black marks in the nail plate
  • Transverse or longitudinal ridging
  • Pitting
  • Onycholysis (separation of nail from nail bed)
  • Subungual hyperkeratosis 1

• Note that fingernails are more commonly affected than toenails in Candida infections associated with Raynaud's 1

Management Considerations

For patients with Raynaud's and associated nail changes:

1. Treat the underlying Raynaud's phenomenon:

   • Calcium channel blockers (e.g., nifedipine) as first-line therapy 3
   • PDE5 inhibitors (sildenafil, tadalafil) for those who fail or cannot tolerate CCBs 3
   • Bosentan for prevention of new digital ulcers in severe cases 3

2. Address fungal infections if present:

   • Topical antifungals may be considered for early, limited nail involvement 1
   • Amorolfine 5% nail lacquer applied once or twice weekly for 6-12 months 1
   • Systemic antifungals may be necessary for extensive involvement

3. Prevent complications:

   • Regular monitoring for digital ulcers, which have high risk of progression to gangrene (22.5%) and osteomyelitis (11%) 3
   • Antibiotics only when infection is suspected, not as routine treatment 3

Important Caveats

• Nail changes may be the first sign of a developing connective tissue disease, particularly in older patients with new-onset Raynaud's 4

• The presence of nail abnormalities in Raynaud's should prompt evaluation for secondary causes, including systemic sclerosis, lupus, and other connective tissue disorders 3

• Distinguishing between primary nail pathology and Raynaud's-associated changes is important for appropriate management 5

• Prevention strategies include avoiding cold exposure, smoking cessation, and protecting hands from trauma 3