PassFinals
Musculoskeletal

Raynaud's Phenomenon

Raynaud's phenomenon is episodic digital vasospasm triggered by cold or stress, causing sharply demarcated colour change, numbness and pain. Primary disease is usually benign, but later-onset, asymmetric or tissue-damaging disease may be secondary to systemic sclerosis, another connective-tissue disorder, large-vessel disease, vibration or medicines.

In a nutshell

Raynaud's phenomenon is episodic digital vasospasm triggered by cold or stress. Primary disease is usually symmetrical, non-destructive and begins young. Later-onset, asymmetric or tissue-damaging disease suggests secondary Raynaud's, particularly systemic sclerosis. Keep warm and remove triggers, consider a dihydropyridine calcium-channel blocker for troublesome symptoms, and urgently escalate digital ischaemia or ulcers.

Classic presentation

A young person has brief symmetrical episodes of white or blue fingers in the cold, with normal pulses, normal nailfolds and no ulcers. In an older person with new asymmetric attacks, puffy fingers or fingertip ulceration, investigate and refer for secondary disease.

Key points

  • Triphasic white-blue-red change is classic but not required; cold or emotional stress may trigger numbness, pain or colour change.
  • Primary Raynaud's is usually young-onset, symmetrical and non-destructive; ulcers, pitting scars and gangrene indicate another process.
  • Secondary clues include later onset, asymmetry, abnormal nailfolds, positive autoantibodies, puffy fingers, skin tightening, telangiectasia and systemic symptoms.
  • Systemic sclerosis is the key connective-tissue association, and Raynaud's may precede other features.
  • Use warmth, trigger avoidance, smoking cessation and medicine review for all; a dihydropyridine calcium-channel blocker is a common first-line drug for troublesome symptoms.
  • Severe systemic-sclerosis digital ischaemia is urgent; refractory Raynaud's may require PDE5 inhibitors or IV prostanoids, and digital ulcers have a separate specialist treatment pathway.
  • Use current BNF and local policy for doses and interactions, especially hypotension and interactions between nitrates and PDE5 inhibitors.

First-line investigation

History and vascular examination with nailfold assessment; use ANA and targeted blood tests when secondary disease is possible, and refer for specialist capillaroscopy or organ assessment as indicated.

Management

Protect threatened tissue

  • Urgently assess severe persistent pain, necrosis, black or blue tissue, ulceration, infection, absent pulses or rapidly worsening ischaemia.3,4,2

Classify primary or secondary disease

  • Use the history, pulses, nailfolds, connective-tissue examination, ANA and targeted tests to identify an underlying disease or alternative vascular cause.3,1,2

Reduce attacks and triggers

  • Keep warm, avoid sudden cold and vibration, stop smoking, review vasoconstricting medicines safely and consider a dihydropyridine calcium-channel blocker for troublesome symptoms.1,2,5

Treat refractory secondary vasculopathy

  • Through specialist services, consider PDE5 inhibitors or IV prostanoids for refractory systemic-sclerosis Raynaud's and specific ulcer treatment with sildenafil or tadalafil, bosentan or prostanoids.3,4,5

Reassess for connective-tissue disease and tissue injury

  • Review attacks, blood pressure, ulcers, infection, new systemic features and medicine adverse effects; repeat assessment when the pattern changes.3,1,2

Exam traps

  • Primary Raynaud's should not cause ulcers, pitting scars or gangrene.
  • A normal pulse does not exclude digital microvascular disease, but an absent pulse suggests a large-vessel process that needs a different assessment.
  • New severe or asymmetric symptoms are not simply benign primary Raynaud's.
  • Digital ulcer management is not the same as uncomplicated Raynaud's symptom control.
  • Do not combine nitrates with PDE5 inhibitors because of hypotension risk, and do not quote specialist vasodilator doses from memory.

Illustrations

Digital colour change in Raynaud's phenomenonA clinical photograph showing sharply demarcated pallor and blue-purple cyanosis affecting several fingers during an attack. The image must preserve the colour contrast and not imply that every attack is triphasic.Ajean14, Wikimedia Commons · CC-BY-SA-4.0
Digital ulceration in secondary Raynaud'sA clinical photograph of fingertip ulceration or pitting scar illustrating tissue injury in secondary disease. Provide appropriate clinical context and check legibility in the separate image-quality campaign.Frank Breuckmann, Thilo Gambichler, Peter Altmeyer and Alexander Kreut, Wikimedia Commons · CC-BY-2.0

Key sources

  1. NHS Highland, Raynaud's Phenomenon Guidelines (NHS Highland adult therapeutic guideline, last reviewed 5 March 2024)Updated 5 Mar 2024
  2. NHS Tayside, Raynaud's Phenomenon (NHS Scotland local referral and treatment guidance for primary and secondary Raynaud's)
  3. British Society for Rheumatology guideline for management of systemic sclerosis (BSR guideline, Rheumatology 2024;63:2956-2975, including Raynaud's and digital vasculopathy recommendations)Published 11 Sept 2024
  4. NHS England, Clinical commissioning policy: sildenafil and bosentan for the treatment of digital ulceration in systemic sclerosis in adults (NHS England specialised commissioning policy for adult systemic-sclerosis digital ulceration)
  5. BNF, nifedipine, phosphodiesterase-5 inhibitors, prostanoids and bosentan (Current UK prescribing source for dose, contraindications, interactions and monitoring; direct access was restricted and no browser session was available, so detailed regimens were omitted)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.