Raynaud's Phenomenon & Raynaud's Syndrome

What Is Raynaud's Phenomenon?

Raynaud's is a disorder that affects the blood vessels in the fingers, toes, ears, and nose. This disorder is characterised by episodic attacks, called vasospastic attacks, that cause the blood vessels in the fingers and toes to constrict. Raynaud's can occur on its own, or it can be secondary to another condition such as scleroderma or lupus.

Is it Raynaud's syndrome, Raynaud's phenomenon or Raynaud's disease?

There is a lot of confusion on the internet regarding Raynaud's so we thought it was important to spell out the differences in terminology early on in this article which we will expand on later. The name Raynaud's Disease was given to this condition by a French doctor, Maurice Raynaud in 1862 when he first described the phenomenon. The name Raynaud's disease has more recently been replaced with Raynaud's on its own or Raynaud's phenomenon. Raynaud's can be subdivided into primary and secondary conditions and the secondary form is also known as Raynaud's syndrome.

Who does Raynauds affect?

Although estimates vary, recent surveys show that Raynaud's syndrome may affect 5 to 10 percent of the general population. Women are more likely than men to have the disorder. Raynaud's syndrome appears to be more common in people who live in colder climates. However, people with the disorder who live in milder climates may have more attacks during periods of colder weather.

What Happens During an Attack?

For most people, an attack is usually triggered by exposure to cold or emotional stress. In general, attacks affect the fingers or toes but may affect the nose, lips, or ear lobes.

Reduced Blood Supply to the Extremities

When a person is exposed to cold, the body's normal response is to slow the loss of heat and preserve its core temperature. To maintain this temperature, the blood vessels that control blood flow to the skin surface move blood from arteries near the surface to veins deeper in the body. For people who have Raynaud's syndrome, this normal body response is intensified by the sudden spasmodic contractions of the small blood vessels (arterioles) that supply blood to the fingers and toes. The arteries of the fingers and toes may also collapse. As a result, the blood supply to the extremities is greatly decreased, causing a reaction that includes skin discoloration and other changes.

Changes in Skin Colour and Sensation

Once the attack begins, a person may experience three phases of skin colour changes (white, blue, and red) in the fingers or toes. The order of the changes of colour is not the same for all people, and not everyone has all three colours. Pallor (whiteness) may occur in response to spasm of the arterioles and the resulting collapse of the digital arteries. Cyanosis (blueness) may appear because the fingers or toes are not getting enough oxygen-rich blood. The fingers or toes may also feel cold and numb. Finally, as the arterioles dilate (relax) and blood returns to the digits, rubor (redness) may occur. As the attack ends, throbbing and tingling may occur in the fingers and toes. An attack can last from less than a minute to several hours.

How Is Raynaud's Classified?

Doctors classify Raynaud's as either the primary or the secondary form (also known as Raynaud's Syndrome). In medical terms, "primary Raynaud’s" may also be called Raynaud's disease or idiopathic Raynaud's. The terms idiopathic and primary both mean that the cause is unknown.

Primary Raynaud's or Raynaud's disease

Most people who have Raynaud's have the primary form (the milder version). A person who has primary Raynaud's has no underlying disease or associated medical problems. More women than men are affected, and approximately 75 percent of all cases are diagnosed in women who are between 15 and 40 years old.

People who have only vasospastic attacks for several years, without involvement of other body systems or organs, rarely have or will develop a secondary disease (that is, a connective tissue disorder such as scleroderma) later. Several researchers who studied people who appeared to have primary Raynaud's over long periods of time found that less than 9 percent of these people developed a secondary disease.

Secondary Raynaud's or Raynaud's Syndrome

Although secondary Raynaud's (Raynaud's syndrome) is less common than the primary form, it is often a more complex and serious disorder. Secondary means that patients have an underlying disease or condition that causes Raynaud's Syndrome. Connective tissue diseases are the most common cause of Raynaud's syndrome. Some of these diseases reduce blood flow to the digits by causing blood vessel walls to thicken and the vessels to constrict too easily. Raynaud's syndrome is seen in approximately 85 to 95 percent of patients with scleroderma and mixed connective tissue disease, and it is present in about one-third of patients with systemic lupus erythematosus. Raynaud's syndrome also can occur in patients who have other connective tissue diseases, including Sjogren's syndrome, dermatomyositis and polymyositis.

Possible causes of Raynaud's syndrome, other than connective tissue diseases, are carpal tunnel syndrome and obstructive arterial disease (blood vessel disease). Some drugs, including beta-blockers (used to treat high blood pressure), ergotamine preparations (used for migraine headaches), certain agents used in cancer chemotherapy, and drugs that cause vasoconstriction (such as some over-the-counter cold medications and narcotics), are linked to Raynaud's syndrome.

People in certain occupations may be more vulnerable to secondary Raynaud's syndrome. Some workers in the plastics industry (who are exposed to vinyl chloride) develop a scleroderma-like illness, of which Raynaud's syndrome can be a part. Workers who operate vibrating tools can develop a type of Raynaud's syndrome called vibration-induced white finger (VWF) or hand arm vibration syndrome (HAVS).

When Raynaud's syndrome is associated with scleroderma (Systemic Sclerosis) problems may involve skin ulcers (sores) or gangrene (tissue death) in the fingers or toes. Painful ulcers and gangrene are fairly common and can be difficult to treat. In addition, a person may experience heartburn or difficulty in swallowing. These two problems are caused by weakness in the muscle of the oesophagus (the tube that takes food and liquids from the mouth to the stomach) that can occur in people with connective tissue diseases. However, the more serious consequences are caused by involvement of the lungs,heart, kidneys and blood vessels.

How Does a Doctor Diagnose Raynaud's ?

If a doctor suspects Raynaud's, he or she will ask the patient for a detailed medical history. The doctor will then examine the patient to rule out other medical problems. The patient might have a vasospastic attack during the visit, which makes it easier for the doctor to diagnose Raynaud's. Most doctors find it fairly easy to diagnose Raynaud's phenomenon but more difficult to identify the form of the disorder.

Nailfold capillaroscopy (study of capillaries under a microscope) can help the doctor distinguish between primary and secondary Raynaud's (Raynaud's syndrome). During this test, the doctor puts a drop of oil on the patient's nailfolds, the skin at the base of the fingernail. The doctor then examines the nailfolds under a microscope to look for abnormalities of the tiny blood vessels called capillaries. If the capillaries are enlarged or deformed, the patient may have a connective tissue disease and should be referred to a specialist centre.

The doctor may also order two particular blood tests, an antinuclear antibody test (ANA) and an erythrocyte sedimentation rate (ESR). The ANA test determines whether the body is producing special proteins (antibodies) often found in people who have connective tissue diseases or other autoimmune disorders. The ESR test is a measure of inflammation in the body and tests how fast red blood cells settle out of unclotted blood. Inflammation in the body causes an elevated ESR.

Diagnostic Criteria for Raynaud's

Primary Raynaud's Phenomenon

• Periodic vasospastic attacks of pallor or cyanosis (some doctors include the additional criterion of the presence of these attacks for at least 2 years)
• Normal nailfold capillary pattern
• Negative antinuclear antibody test
• Normal erythrocyte sedimentation rate
• Absence of pitting scars or ulcers of the skin, or gangrene (tissue death) in the fingers or toes

Secondary Raynaud's Syndrome

• Periodic vasospastic attacks of pallor and cyanosis
• Abnormal nailfold capillary pattern
• Positive antinuclear antibody test
• Abnormal erythrocyte sedimentation rate
• Presence of pitting scars or ulcers of the skin, or gangrene in the fingers or toes

What Is the Treatment for Raynaud's?

The aims of treatment are to reduce the number and severity of attacks and to prevent tissue damage and loss in the fingers and toes. Most doctors are conservative in treating patients with Raynaud's that is, they recommend non-drug treatments and self-help measures first. Doctors may prescribe medications for some patients, usually those with secondary Raynaud's syndrome. In addition, patients are treated for any underlying disease or condition that causes secondary Raynaud's syndrome.

Non-drug Treatments and Self-Help Measures

Several nondrug treatments and self-help measures can decrease the severity of Raynaud's attacks and promote overall well-being.

Take action during an attack

An attack should not be ignored. Its length and severity can be lessened by a few simple actions. The first and most important action is to warm the hands or feet. In cold weather, people should go indoors. Running warm water over the fingers or toes or soaking them in bowls of alternate cool and warm water will warm them. Taking time to relax will further help to end the attack. If a stressful situation triggers the attack, a person can help stop the attack by getting out of the stressful situation and relaxing. People who are trained in biofeedback can use this technique along with warming the hands or feet in water to help lessen the attack.

Keep warm

It is important not only to keep the extremities warm but also to avoid chilling any part of the body. In cold weather, people with Raynaud's must pay particular attention to dressing. Several layers of loose clothing, socks, hats, and gloves or mittens are recommended. A hat is important because a great deal of body heat is lost through the head. Feet should be kept dry and warm. Some people find it helpful to wear mittens and socks for bed during winter. Chemical warmers, such as small heating pouches that can be placed in pockets, mittens, boots, or shoes, can give added protection during long periods outdoors.Visit www.raynauds.org.uk for information on useful recommended products. People who have secondary Raynaud's should talk to their doctors before exercising outdoors in cold weather.

People with Raynaud's syndrome should also be aware that air conditioning can trigger attacks. Turning down the air conditioning or wearing a sweater may help prevent attacks. Some people find it helpful to use insulated drinking glasses and to put on gloves before handling frozen or refrigerated foods.

Quit smoking

The nicotine in cigarettes causes the skin temperature to drop and the small arteries to constrict which may lead to an attack.

Control stress

Because stress and emotional upsets may trigger an attack, particularly for people who have primary Raynaud's, learning to recognise and avoid stressful situations may help control the number of attacks. Many people have found that relaxation or biofeedback training can help decrease the number and severity of attacks. Biofeedback training teaches people to bring the temperature of their fingers under voluntary control. Local hospitals and other community organisations, such as schools, often offer programmes in stress management.

Exercise

Many doctors encourage patients who have Raynaud's, particularly in the primary form, to exercise regularly. Most people find that exercise promotes overall well-being, increases energy level, helps control weight, and promotes restful sleep. Patients with Raynaud's should talk to their doctors before starting an exercise programme.

See a doctor

People with Raynaud's should see their doctors if they are worried or frightened about attacks or if they have questions about caring for themselves. They should always see their doctors if attacks occur only on one side of the body (one hand or one foot) and any time if an attack results in sores or ulcers on the fingers or toes.

Treatment With Medications

People with Raynaud's syndrome are more likely than those with primary Reynaud's phenomenon to be treated with medications. Many doctors believe that the most effective and safest drugs are calcium-channel blockers, which relax smooth muscle and dilate the small blood vessels. These drugs decrease the frequency and severity of attacks in about two-thirds of patients who have Raynaud's.

Some patients have found relief with drugs called alpha blockers that counteract the actions of norepinephrine, a hormone that constricts blood vessels. Some doctors prescribe a nonspecific vasodilator (drug that relaxes blood vessels), such as nitroglycerine paste or patches. Patients should keep in mind that the treatment for Raynaud's is not always successful. Often, patients with Raynaud's syndrome will not respond as well to treatment as those with the primary form of the disorder.

Patients may find that one drug works better than another. Some people may experience side effects that require stopping the medication. For other people, a drug may become less effective over time. Women of childbearing age should know that the medications used to treat Raynaud's may affect the growing foetus. Therefore, women who are pregnant or are trying to become pregnant should avoid taking these medications if possible.

What about Reynaud's - is this different from Raynaud's?

Many people spell it in different ways but they are one and the same thing. The name Raynaud’s was given to the condition by a French physician - Dr Maurice Raynaud in 1862. Hence the name!