What are the physical exam findings in Raynaud’s phenomenon?

Physical Exam Findings in Raynaud's Phenomenon

The physical examination in primary Raynaud's phenomenon is typically unremarkable between attacks, while secondary Raynaud's may reveal signs of underlying connective tissue disease, digital ulcers, or tissue necrosis. 1

During an Active Attack

• Triphasic color changes are the hallmark finding, progressing from white (pallor due to vasoconstriction) to blue (cyanosis) to red (reactive hyperemia during reperfusion) 2, 3, 4
• The color changes are sharply demarcated and typically affect individual digits rather than the entire hand in primary Raynaud's 5
• In secondary Raynaud's, the entire hand may be involved rather than just isolated digits 6
• Attacks are usually triggered by cold exposure or emotional stress 2, 4

Between Attacks: Primary Raynaud's

• Physical examination is usually unremarkable in primary (idiopathic) Raynaud's phenomenon 1
• No digital ulcers, tissue necrosis, or gangrene are present 7
• Peripheral pulses should be normal 8
• No signs of underlying connective tissue disease 1

Between Attacks: Secondary Raynaud's - Red Flags

A thorough neurologic and rheumatologic examination is essential to identify secondary causes. 1

Digital Complications

• Digital ulcers are present in 22.5% of patients with systemic sclerosis-associated Raynaud's 6
• Tissue necrosis or gangrene occurs in 11% of systemic sclerosis patients 6
• Digital pitting scars from healed ulcers 7
• In extreme cases, evidence of osteomyelitis or prior amputation 6

Skin Findings Suggesting Connective Tissue Disease

• Skin thickening or tightness (sclerodactyly in systemic sclerosis) 7
• Telangiectasias 7
• Calcinosis cutis 7
• Photosensitive rash (suggesting systemic lupus erythematosus) 6

Vascular Findings

• Abnormal or absent peripheral pulses suggesting atherosclerosis or thromboangiitis obliterans 7, 3
• Signs of peripheral arterial disease 7
• Evidence of thromboembolic disease 7

Neurologic Findings

• Peripheral neuropathy on neurologic examination 1
• Radiculopathy findings 1
• These findings suggest secondary causes requiring further workup 1

Musculoskeletal Findings

• Joint swelling or deformities (suggesting rheumatoid arthritis) 7, 6
• Muscle weakness 6
• Synovitis 7

Nail Fold Capillaroscopy

• Nail fold capillaroscopy is the gold standard for distinguishing primary from secondary Raynaud's phenomenon 4
• Abnormal capillary patterns (dilated capillaries, capillary dropout, hemorrhages) strongly suggest secondary Raynaud's, particularly systemic sclerosis 4
• Normal capillary patterns support primary Raynaud's diagnosis 4

Common Pitfalls to Avoid

• Do not assume primary Raynaud's without a thorough examination - missing secondary causes, especially systemic sclerosis, leads to delayed diagnosis and poor outcomes including digital ulcers 9
• Always perform a complete neurologic examination to identify peripheral neuropathy or radiculopathy as secondary causes 1
• Look carefully for subtle signs of connective tissue disease including skin changes, joint findings, and systemic symptoms 7, 6
• Examine all digits carefully for ulcers or scars - digital complications are the most serious manifestation requiring aggressive treatment 7, 6