From the Guidelines
To assess for Raynaud's phenomenon, begin with a thorough history focusing on episodes of color changes in fingers or toes (typically white, then blue, then red) triggered by cold exposure or stress, as recommended by recent guidelines 1. Ask about pain, numbness, or tingling during these episodes, their frequency, duration, and severity. Perform a physical examination looking for skin changes, ulcerations, or scars on fingertips. During the exam, you can conduct a cold challenge test by having the patient immerse hands in cold water (about 15°C) for 20 seconds and observe for characteristic color changes. Nailfold capillaroscopy may be performed to examine the capillaries at the base of the fingernails, which can help distinguish between primary and secondary Raynaud's. Laboratory tests including antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR), and complete blood count can help identify underlying autoimmune conditions that might cause secondary Raynaud's. Some key points to consider in the assessment and management of Raynaud's phenomenon include:
- Avoiding triggers such as cold, trauma, stress, smoking, vibration injury, or certain drugs 1
- Using proper clothing in cold conditions, such as gloves and heating devices for the hands, and avoiding direct contact with cold surfaces 1
- Considering physical exercise as a management strategy to improve symptoms and patient outcomes 1 Raynaud's assessment is important because early identification, particularly of the secondary form, can lead to earlier treatment of potentially serious underlying conditions like scleroderma, lupus, or other connective tissue diseases. The most recent and highest quality evidence supports the use of nifedipine as a first-line treatment for Raynaud's phenomenon, due to its clinical benefit, low cost, and acceptable adverse effects 1.
From the Research
Assessment of Raynaud's Phenomenon
To assess for Raynaud's phenomenon, the following steps can be taken:
- A detailed clinical history and careful physical examination may be helpful in identifying the cause 2
- Routine investigations include:
- Full blood count
- Measurement of erythrocyte sedimentation rate
- C‑reactive protein
- Antinuclear antibody levels
- Biochemical profile
- Thyroid function tests
- Protein electrophoresis
- Chest X‑ray
- Nailfold capillaroscopy 2
- Capillaroscopy can facilitate a very early diagnosis of systemic sclerosis (SSc) 2
- Doppler ultrasound is recommended to evaluate the risk of pathologies in large to medium-sized arteries 2
- Digital photoplethysmography and pulse contour analysis can be used as an additional tool to exclude structural macro- or microvascular disease 3
Differentiating Between Primary and Secondary Raynaud's
Differentiating between primary and secondary Raynaud's is important as secondary Raynaud's can be complicated by digital ischemia and gangrene whereas primary Raynaud's is generally a benign condition 4
- Primary Raynaud's occurs without underlying disease and is considered a benign condition 3
- A normal erythrocyte sedimentation rate, negative testing for antinuclear antibodies, normal nailfold capillaries and the absence of structural micro- or macrovascular damage and other diseases lead to the diagnosis of primary Raynaud's 3
- Secondary Raynaud's is associated with other diseases, mainly connective tissue diseases such as systemic sclerosis 3
Referral and Further Evaluation
Referral to a rheumatologist is recommended to help evaluate for an underlying rheumatologic condition and to guide future therapy 4
- If there is a suspicion of secondary Raynaud's, a thorough laboratory and vascular assessment is required to make the diagnosis of underlying disease 3