When to Refer Patients with Raynaud's Phenomenon
Patients with Raynaud's phenomenon should be referred to a specialist when there are signs of secondary Raynaud's, evidence of tissue damage, or when symptoms significantly impact quality of life despite first-line management. 1, 2
Urgent Referral Indications
Digital ischemia or tissue damage: Patients with signs of critical ischemia, digital ulceration, or gangrene require urgent referral to prevent permanent tissue damage 2, 3
Suspected giant cell arteritis: Patients over 50 years with Raynaud's and symptoms of GCA (headache, scalp tenderness, jaw claudication, visual disturbances) require immediate referral to prevent permanent visual loss 1
Retinal or ophthalmic artery occlusion: Patients with Raynaud's who develop acute, painless vision loss should be immediately referred to an emergency department or stroke center due to high risk of concurrent cerebrovascular events 1
Indications for Specialist Referral
Signs of Secondary Raynaud's
- Onset after age 30 3
- Asymmetric or severe symptoms 2
- Associated systemic symptoms (joint pain, skin changes, dysphagia) 4
- Abnormal nailfold capillaroscopy findings 4
- Positive autoantibodies suggesting connective tissue disease 3
Disease Severity Indicators
- Symptoms that extend beyond individual digits to involve the entire hand 2
- Frequent, prolonged, or painful attacks despite conservative management 1
- Development of digital ulcers or other tissue damage 2, 5
- Significant impact on hand function and daily activities 1
Treatment Considerations
- Failure to respond to first-line therapies including calcium channel blockers 2, 6
- Need for advanced pharmacological therapies (phosphodiesterase-5 inhibitors, prostacyclin analogues) 2
- Consideration for botulinum toxin injections or surgical sympathectomy 5
Specific Conditions Requiring Referral
Suspected Systemic Sclerosis
- Raynaud's with skin thickening, puffy fingers, or sclerodactyly 1, 2
- Raynaud's with telangiectasia and calcinosis 1
- Raynaud's with gastrointestinal symptoms (reflux, dysphagia) 1
Pulmonary Hypertension Concerns
- Raynaud's with unexplained dyspnea, especially in patients with known systemic sclerosis 1
- Echocardiographic findings suggesting elevated pulmonary pressures 1
Management Prior to Referral
- Implement cold avoidance strategies and use of gloves/heating devices 1
- Consider calcium channel blockers as first-line pharmacological treatment 2, 6
- Encourage smoking cessation and avoidance of vasoconstrictive medications 7
- Promote regular physical exercise to improve hand function 1
Referral Pathways
- Rheumatology: For suspected connective tissue diseases or when secondary Raynaud's is suspected 3
- Vascular Surgery: For critical digital ischemia, ulceration, or consideration of surgical interventions 2
- Stroke Center/Emergency Department: For associated acute visual symptoms suggesting retinal artery occlusion 1
- Pulmonology: For suspected pulmonary hypertension, particularly in systemic sclerosis patients 1
Common Pitfalls to Avoid
- Delaying referral for patients with digital ulceration or tissue necrosis 2, 3
- Failing to recognize Raynaud's as an early manifestation of systemic sclerosis or other connective tissue diseases 4, 3
- Overlooking the need for vascular imaging in patients with asymmetric or unilateral symptoms 7
- Assuming all Raynaud's is benign without appropriate evaluation for secondary causes 3