Family doctor

``OVERVIEW

Raynaud's syndrome is a painful condition usually affecting the hands and feet. A few with the condition may develop another rheumatoligical condition in the future and this may be predicted using various tests. Treatment includes preventative care, medications and, rarely, surgery.

What is Raynaud's syndrome?

Raynaud's syndrome is due to poor circulation, usually in the hands and feet, although may affect the nose, tongue or ears. The tiny blood vessels in the affected area close down, supplying very little blood to the extremities. Numbness results and on warming, the area may throb painfully.

When Raynaud's syndrome occurs alone it is known as primary Raynaud's; when it occurs with another related condition it is known as secondary Raynaud's syndrome.

Raynaud's can be a useful predictor of autoimmune rheumatic disease.

How common is Raynaud's?

Raynaud's syndrome occurs in up to 5% of typical healthy populations. Over 90% of patients with Raynaud's phenomenon are female and under 25 years of age when they first develop the syndrome. Up to 5% of patients presenting with the condition eventually develop an autoimmune rheumatic disease.

What are the symptoms of Raynaud's?

Raynaud's syndrome occurs on and off, usually as a response to cold or, rarely, as an emotional reaction. The affected areas, usually fingers or toes, turn very white or blue and become numb when cold. On warming, they turn bright red and throb painfully.

 Underlying causes of Raynaud's syndrome

 Underlying causes of Raynaud's may include:

• Occupation - outdoor workers, use of vibrating tools, chemical exposure (eg vinyl chloride).
• Medications - ß (Beta) blockers, ergotamines, oral contraceptives, bleomycin.
• Blockages to blood vessels - proximal vascular occlusion.
• Other connective tissue disorders (eg Arthralgia or arthritis, Alopecia, skin rashes, cerebral symptoms, photosensitivity, dry eyes or mouth, mouth ulcers, muscle weakness, respiratory or cardiac problems).

 Diagnosis of Raynaud's syndrome and related conditions

 Diagnosis of primary and secondary Raynaud's syndrome includes clinical examination and laboratory investigations.

The most simple examination is viewing of the affected area during or soon after an episode, by a doctor. Further physical examination includes assessment of peripheral pulses, measurement of blood pressure in both arms, and examination of the neck for tenderness often associated with a cervical rib.

 Raynaud's syndrome may be mistaken for chilblains by sufferers, so continued episodes of suspected chilblains should be checked by a doctor.

 The development of gangrene due to Raynaud's syndrome is relatively rare, and because patients are often young, recovery may be remarkable.

 Up to 5% of patients with Raynaud's syndrome eventually develop an autoimmune rheumatic disease.

 What are autoimmune rheumatic diseases and how are they predicted?

 Up to 5% of patients with Raynaud's syndrome eventually develop an autoimmune rheumatic disease. The most common related diseases and their incidence of development to Raynaud's sufferers are;

• Rheumatoid arthritis <5%
• Systemic lupus erythematosus 20-30%
• Sjogrens syndrome 20-30%
• Myositis 25%
• Scleroderma >95% 

 A variety of tests are undertaken to predict development:

•   Full blood count and erythrocyte (red blood cell) sedimentation rate
• Total immunoglobulin (immune system protein) and electrophoresis strip (measurement of molecules)
• Urine analysis
• Renal and liver function tests
• Nail fold capillaroscopy
• Test for antinuclear antibody
• Chest x rays
• Hand x rays 

 It is important to note that a negative test for antinuclear antibody in an otherwise healthy patient does not exclude future development of an autoimmune rheumatic disease.

 Different types of antinuclear antibody may be specific for certain diseases and so may help diagnosis. A variety of investigations may be used to measure vasular (blood vessel) problems, including Plethysmography, Doppler ultrasonography, and laser Doppler flowmetry with direct capillaroscopy and thermal entrainment.

 How is Raynaud's treated?

 Those with Raynaud's syndrome having no symptoms other than changes to color of affected areas may only need prevention measures to avoid complications.

 Some Raynaud's syndrome patients have claimed improvement after changing to diets supplemented with fish oils.

 Ulcers or sores on the tips of the fingers or toes should be monitored closely by the doctor as these can become infected. Gently applied finger splints are used to protect ulcerated areas. Ointments to open blood vessels (nitroglycerin ointment) are sometimes used on the sides of severely affected digits to allow increased blood supply and healing.

 Severe Raynaud's can lead to gangrene and the loss of fingers or toes. In rare severe cases, nerve surgery called "sympathectomy" may be considered. The nerves stimulatingconstriction of the vessels are surgically interrupted in order to prevent blood vessel spasms.

 Some patients with primary Raynaud's and most with the condition secondary to an underlying autoimmune rheumatic disease require drug treatment. Medication appropriate to the individual patient should be discussed with a doctor.

 What medications are used to treat Raynaud's syndrome?

 Patients with persistent or bothersome symptoms may be helped by taking oral medications to open (dilate) blood vessels,including calcium channel blockers - a modified release of this preparation reduces the common side effects of headache and flushing. Other medicines used for blood pressure treatment may help dilation. Medications that "thin" the blood, such as low doses of aspirin or dipyridamole may be helpful.

 Some patients with persistent symptoms can benefit by a medication to make red blood cells more pliable and improve circulation, called toxifylline.

 Some medications can aggravate symptoms by increasing blood vessel spasms. Such medications include over-the-counter cold and weight-control preparations, such as phenylpropanolamine and pseudoephedrine found in some cold and flu or headache medications. "Beta-blocker" medicines used for high blood pressure and heart disease can also worsen Raynaud's.

 Prevention and care

 Prevention measures are important in primary and secondary Raynaud's syndrome regardless of the severity. Initial simple care:

•   Keep the body warm, especially the extremities.
• Wear warm clothing in colder environments.
• Use cotton gloves while searching the freezer.
• Keep room temperatures warm.
• Use rubber gloves to protect the hands and prevent cooling while dish washing.
• Minimise barefoot walking.
• Avoid compression of the blood vessels by tight-fitting wrist bands, rings or foot wear.
• Special care of nails is needed to avoid injuring sensitive toes and fingertips.

Smoking(and passive smoking) should be avoided as the chemicals in tobacco smoke can cause blood vessels to constrict and harden the arteries, which further impairs oxygen supply to the extremities.

 Patients should guard hands and feet from direct trauma and wounds. Any wounds or infections need early treatment to prevent more serious infections. Avoiding emotional stresses and tools that vibrate the hand may reduce the frequency of attacks.