What is the recommended prednisone (corticosteroid) treatment course for a patient experiencing a Raynaud's (Raynaud's phenomenon) flare-up?

Prednisone is NOT Recommended for Raynaud's Phenomenon Flare-Ups

Corticosteroids, including prednisone, have no established role in the treatment of Raynaud's phenomenon flare-ups and should not be used for this indication. The available evidence-based guidelines for Raynaud's management do not include systemic corticosteroids as a treatment option for either primary or secondary Raynaud's phenomenon 1, 2, 3.

Why Corticosteroids Are Not Indicated

The pathophysiology of Raynaud's phenomenon involves vasospasm of digital arteries triggered by cold exposure or emotional stress, not an inflammatory process that would respond to corticosteroids 1. Unlike inflammatory conditions such as rheumatoid arthritis where prednisone has disease-modifying effects 4, Raynaud's requires vasodilatory therapy to address the underlying vasospastic mechanism 2, 5.

Evidence-Based Treatment Algorithm for Raynaud's Flare-Ups

First-Line Management (All Patients)

• Implement non-pharmacological measures immediately: cold avoidance with proper warm clothing including mittens, hat, and insulated footwear 1
• Smoking cessation is mandatory, as smoking exacerbates vasospasm 1, 2
• Avoid triggering medications including beta-blockers, ergot alkaloids, bleomycin, and clonidine 1
• Use heating devices for hands and avoid direct contact with cold surfaces 1

Pharmacological Treatment for Symptomatic Relief

For Primary or Secondary Raynaud's:

• Nifedipine (dihydropyridine calcium channel blocker) is the established first-line pharmacological treatment, reducing both frequency and severity of attacks 2, 5, 6
• Typical dosing uses long-acting preparations to minimize adverse effects like ankle swelling, headache, and flushing 5

If Inadequate Response to Calcium Channel Blockers:

• Add or switch to phosphodiesterase-5 inhibitors (sildenafil or tadalafil), which effectively reduce frequency, duration, and severity of attacks 2, 3

For Severe Secondary Raynaud's Unresponsive to Oral Therapies:

• Intravenous iloprost is recommended for severe cases 1, 7

Management of Digital Ulcers (Secondary Raynaud's)

If digital ulcers are present or developing:

• Bosentan (endothelin receptor antagonist) prevents new digital ulcers, particularly in patients with ≥4 digital ulcers at baseline 2
• Intravenous iloprost is effective for healing existing digital ulcers 2
• Phosphodiesterase-5 inhibitors are effective for both healing and prevention 2

Critical Pitfalls to Avoid

• Do not prescribe prednisone or other corticosteroids for Raynaud's flare-ups, as there is no evidence supporting their use and they do not address the vasospastic pathophysiology 1, 2
• Do not combine topical nitroglycerin with phosphodiesterase-5 inhibitors due to contraindication 2
• Do not delay treatment in secondary Raynaud's, as this can result in digital ulcers, gangrene, and other complications 1
• Screen for secondary causes (especially systemic sclerosis) in patients with severe, painful episodes, digital ulcers, or involvement of entire hand rather than individual digits 1

When to Escalate Care

Consider specialist referral if:

• Digital ulcers, tissue necrosis, or gangrene develop 1
• Inadequate response to calcium channel blockers and phosphodiesterase-5 inhibitors 2
• Signs of underlying connective tissue disease emerge (joint deformities, scleroderma changes, facial rosacea) 1