Initial Treatment for Raynaud's Disease
The initial treatment for Raynaud's disease begins with mandatory lifestyle modifications including cold avoidance, smoking cessation, and trigger avoidance, followed by nifedipine (a dihydropyridine calcium channel blocker) as first-line pharmacotherapy when symptoms affect quality of life. 1
Non-Pharmacological Management (Always First-Line)
All patients must implement trigger avoidance and lifestyle modifications before or alongside any pharmacotherapy 1:
- Cold avoidance is essential—wear proper warm clothing including coat, mittens (not gloves), hat, dry insulated footwear, and use hand/foot warmers 2, 1
- Smoking cessation is mandatory, as smoking directly worsens vasospasm and undermines all treatment efforts 1
- Avoid triggering medications including beta-blockers, ergot alkaloids, bleomycin, and clonidine 2, 1
- Stress management techniques help reduce attack frequency, as emotional stress triggers vasospasm 1
- Avoid vibration injury and repetitive hand trauma, particularly in occupational settings 1
- Physical therapy with exercises to generate heat and stimulate blood flow can be beneficial 2, 1
First-Line Pharmacotherapy
Nifedipine (dihydropyridine calcium channel blocker) is the gold-standard first-line pharmacotherapy for both primary and secondary Raynaud's when non-pharmacological measures are insufficient 1:
- Nifedipine reduces both frequency and severity of attacks with acceptable adverse effects and low cost 1
- Extended-release formulations (30 mg at bedtime) reduce side effects like ankle swelling, headache, and flushing 3, 4
- Other dihydropyridine calcium channel blockers can be substituted if nifedipine is poorly tolerated 5
- Expect 70-80% response rate, though 20-50% may develop intolerable side effects 3
Critical Pitfalls to Avoid
Always evaluate for systemic sclerosis and other connective tissue diseases, as delayed diagnosis leads to digital ulcers and poor outcomes 1:
- Red flags for secondary Raynaud's include severe painful episodes, digital ulceration, asymmetric involvement, and onset after age 30 6
- Secondary Raynaud's requires more aggressive therapy and earlier escalation to prevent complications 1
- Never continue triggering medications (especially beta-blockers)—this will undermine all treatment efforts 1
- Delaying escalation in secondary Raynaud's leads to digital ulcers, which occur in 22.5% of systemic sclerosis patients 2, 6
Treatment Algorithm Based on Response
For patients with inadequate response to calcium channel blockers or those with secondary Raynaud's:
- Second-line: Add or switch to phosphodiesterase-5 inhibitors (sildenafil or tadalafil), which effectively reduce attack frequency and severity 1, 5
- Third-line: Consider intravenous prostacyclin analogues (iloprost) for severe Raynaud's unresponsive to oral therapies 1, 5
The key distinction is that primary Raynaud's is often mild enough to manage with lifestyle modifications alone, while secondary Raynaud's typically requires pharmacotherapy due to fixed vascular defects in addition to vasospasm 7, 8.