From the Guidelines
Raynaud's phenomenon affecting the toes should be managed with calcium channel blockers, such as nifedipine, as the first-line treatment, according to the most recent and highest quality evidence available 1. To manage Raynaud's phenomenon, it is essential to start by keeping the feet warm with insulated socks, heated insoles, and avoiding cold exposure. When experiencing an attack, gently warming the feet by soaking them in warm (not hot) water or moving to a warmer environment can help. Avoiding smoking and limiting caffeine intake is also crucial, as these substances constrict blood vessels. Some key points to consider in managing Raynaud's phenomenon include:
- Avoiding triggers such as cold, trauma, stress, smoking, vibration injury, or certain drugs like bleomycin, clonidine, and ergot alkaloids 1
- Using physical therapy to stimulate blood flow, including exercises to generate heat, biofeedback, and laser treatment 1
- Considering topical nitroglycerin ointment (2%) for localized relief in affected toes 1
- In severe cases, phosphodiesterase inhibitors like sildenafil (20 mg three times daily) may be prescribed, but their high cost and potential side effects should be considered 1 It is essential to consult a healthcare provider if symptoms worsen, develop ulcers, or significantly impact daily life, as this could indicate secondary Raynaud's linked to an underlying condition requiring different treatment. The management of Raynaud's phenomenon and digital ulcers in systemic sclerosis (SSc) can be guided by the algorithm suggested in the scientific evidence available, which recommends different lines of treatment and the strength of each recommendation 1.
From the Research
Treatment Options for Raynaud's Phenomenon of the Toes
- Lifestyle modifications may be sufficient to control primary Raynaud's phenomenon, but some patients, and most with secondary Raynaud's, require pharmacologic treatment 2.
- Calcium channel blockers, such as nifedipine, are often considered when treatment is needed, but adverse effects can include hypotension, vasodilatation, peripheral oedema, and headaches 3.
- Other treatments that have been studied include:
- Phosphodiesterase type 5 inhibitors, which have been shown to be beneficial in reducing symptoms 4.
- Intravenous prostanoids, which are used to evaluate the risk of pathologies in large to medium-sized arteries 2.
- Topical nitrates, which can be used to manage Raynaud's phenomenon, but may be limited by adverse effects such as flushing, headache, and hypotension 3.
- Endothelin receptor antagonists, such as bosentan, which have been shown to reduce the number of new digital ulcers in scleroderma patients 3, 4.
- Botulinum toxin therapy, which was ineffective in a clinical trial involving scleroderma patients, but may require further study in other subsets of patients 4.
- Digital sympathectomy, which may be beneficial in cases of critical digital ischemia, but recurrence of symptoms is common 4.
Non-Pharmacological Treatment
- Avoiding cold and smoking cessation are important non-pharmacological approaches for managing Raynaud's phenomenon 3, 5.
- A detailed clinical history and careful physical examination may be helpful in identifying the cause of Raynaud's phenomenon 2.
- Routine investigations, such as a full blood count, measurement of erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody levels, biochemical profile, thyroid function tests, protein electrophoresis, chest X-ray, and nailfold capillaroscopy, may be necessary to diagnose and manage Raynaud's phenomenon 2.
Pharmacological Treatment
- Calcium channel blockers are the most commonly prescribed drugs for people with primary Raynaud's phenomenon, and have been shown to be minimally effective in decreasing the frequency of attacks 6.
- Treatment with oral calcium channel blockers was associated with a number of adverse reactions, including headaches, flushing, and oedema (swelling) 6.
- The choice of pharmacological treatment for Raynaud's phenomenon should be based on the individual patient's needs and medical history, and may involve a combination of different medications 4.