Raynaud's Phenomenon

Raynaud's is a fairly rare disorder of the blood vessels supplying the skin. During a Raynaud's attack, the blood vessels narrow, limiting blood circulation to affected areas. It makes parts of your body (usually fingers, toes, nose and ears) feel numb and cool in cold temperatures or under stress.

Raynaud's can be classified into two types. When it occurs without another disease present, it is called Raynaud's disease (or primary Raynaud's). This is the most common type and typically affects both hands and both feet. Although it can affect men, it most often occurs in women between 15 and 40.

When it occurs as part of another disease, it is called Raynaud's phenomenon (or secondary Raynaud's). This type usually affects either both hands or both feet. Causes may include scleroderma, lupus, rheumatoid arthritis, Sjögren's syndrome, diseases of the arteries, carpal tunnel syndrome, smoking, chemical exposure, certain drugs or injury.

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Symptoms

Raynaud's is more than just having cold hands and feet. It's also not the same as frostbite. Signs of Raynaud's depend on how often, how long and how severe the blood vessel spasms are. Signs and symptoms include:

  • At first during an attack, affected areas of skin usually turn white. They often then turn blue and feel cold and numb. The ability to perceive sensory information is dulled, and the affected skin may look slightly swollen. As circulation improves, the affected areas may turn red, throb, tingle or swell. The order of the color changes is not the same for all people, and not everyone experiences all three colors.
  • Numbness, prickles or stinging pain upon warming or relief of stress
  • Occasionally, an attack affects just one or two fingers or toes. Attacks don't always affect the same digits. Although it most commonly affects your fingers and toes, the condition also can affect other areas of your body, such as your nose, cheeks, ears and even tongue. An attack may last less than a minute to several hours, and over time, attacks may grow more severe.

People who have Raynaud's with another disease also may have symptoms related to their underlying condition.

Causes and Risk Factors

It is not known what causes the blood vessels in the hands and feet to overreact to cold or stress. Women get this disorder more than men, and studies are being done to see if it is an inherited condition.

To help maintain its core temperature, the body naturally cuts down the flow of blood to the hands and feet when temperatures are cold or there is a threat by narrowing the small arteries under the skin of the hands and feet. In people with Raynaud's, this response is exaggerated.

With Raynaud's, arteries to the fingers and toes go into what's called vasospasm, which makes the vessels narrow temporarily to limit the blood supply. In time these same small arteries also may thicken slightly, further limiting blood flow. The affected skin turns pale-dusky-colored from lack of blood. Once the spasms end, blood flows back, but the tissues may turn red before returning to a normal color.

Simple tasks, such as putting hands under running cold water, taking something out of a freezer or exposure to cold air can provoke an attack. Emotional stress can also cause an episode of Raynaud's. Other conditions and activities that put you at increased risk for Raynaud's phenomenon are:

  • Scleroderma. Raynaud's phenomenon occurs in about 90% of people who have scleroderma, a rare disease that leads to hardening and scarring of the skin. Scleroderma results in Raynaud's because the disease reduces blood flow to hands and feet, and it causes tiny blood vessels to thicken and constrict too easily.
  • Lupus. Between 30 and 40% of Americans with lupus (a disease that can affect many parts of the body, including the skin, joints, organs and blood vessels) develop Raynaud's.
  • Rheumatoid arthritis. Raynaud's often is the first sign of rheumatoid arthritis, an inflammatory condition causing pain and stiffness in the body's joints, often including the hands and feet.
  • Sjögren's syndrome. Raynaud's phenomenon can also occur in people who have this rare disorder that often comes with scleroderma, lupus or rheumatoid arthritis. The hallmark of Sjögren's syndrome, a connective tissue disease, is chronic dryness of the eyes and mouth.
  • Diseases of the arteries. Raynaud's phenomenon can occur with diseases that affect arteries, such as Buerger's disease in which the blood vessels of the hands and feet become inflamed.
  • Carpal tunnel syndrome. The carpal tunnel is a narrow passage in your wrist that protects a major nerve to your hand. Carpal tunnel syndrome is a condition in which pressure is put on this nerve, producing numbness and pain in the affected hand. The affected hand may become more susceptible to cold temperatures and episodes of Raynaud's.
  • Repetitive trauma. Raynaud's also can be caused by repetitive trauma that damages nerves serving blood vessels in the hands and feet. Some people who type or play the piano for long periods of time or vigorously may be susceptible to Raynaud's. Workers who use vibrating tools can develop a type of Raynaud's phenomenon called vibration-induced white finger.
  • Smoking. Smoking constricts blood vessels and can cause Raynaud's.
  • Injuries. Injuries to the hands or feet from surgery or frostbite, for example, can lead to Raynaud's phenomenon.
  • Certain drugs. Some drugs, such as beta blockers (used to treat high blood pressure), ones for migraines that have ergotamine, estrogen replacement therapy, certain chemotherapy agents and drugs that cause blood vessels to narrow (such as some over-the-counter cold medications), have been linked to Raynaud's.
  • Chemical exposure. Some plastics industry workers who are exposed to vinyl chloride develop an illness like scleroderma. Raynaud's can be a part of that.
  • Other causes. Raynaud's has also been linked to an overactive thyroid gland (hyperthyroidism), a condition in which blood pressure rises in the blood vessels of the lungs (pulmonary hypertension) and, rarely, to certain cancers.
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Diagnosis

If the doctor suspects Raynaud's, he or she will ask for a detailed description of your symptoms. The doctor also will examine you to rule out other problems that may cause similar symptoms, such as a pinched nerve. Your doctor may do an in-office cold simulation test, which may involve placing your hands in cool water or exposing you to cold air to invoke an episode of Raynaud's.

Most doctors can diagnose Raynaud's from a description of symptoms, but it may be more difficult to identify whether the condition is Raynaud's alone or whether another disease or lifestyle factor is causing the symptoms. The doctor may do an in-office test called nail fold capillaroscopy, in which the skin at the base of the fingernail is examined under a microscope. Tiny blood vessels (capillaries) near the nail fold that are enlarged or deformed may show an underlying disease.

If the doctor suspects that another condition (such as an autoimmune or connective tissue disease) underlies Raynaud's, he or she may order two blood vessel tests.

  • Antinuclear antibody (ANA) test. A positive test for the presence of these antibodies that are produced by the immune system indicates a stimulated immune system. This is common in people who have connective tissue diseases or other autoimmune disorders.
  • Erythrocyte sedimentation rate (ESR). This blood test determines the rate at which red blood cells settle to the bottom of a tube. A faster-than-normal rate may signal an inflammatory or autoimmune disease. Autoimmune diseases are commonly associated with Raynaud's.

There's no single blood test to diagnose Raynaud's. The doctor may order other tests, such as ones to rule out diseases of the arteries or to help pinpoint a disease or condition that may be associated with Raynaud's.

If Raynaud's is severe (which is rare) blood circulation to the fingers or toes could permanently diminish, causing deformities of the fingers or toes. If an artery to an affected area becomes blocked completely, sores (skin ulcers) or dead tissue (gangrene) may develop. Ulcers and gangrene can be difficult to treat. See your doctor right away if you have a history of severe Raynaud's and develop an ulcer or infection in one of your affected fingers or toes.

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Treatments

Treatment of Raynaud's depends on how severe it is and whether there are associated conditions. For most people, Raynaud's is more a nuisance than a disability.

The aims of treatment are to reduce the number and severity of attacks and prevent tissue damage. Doctors also want to treat any underlying disease or condition.

Drugs

Several different types of drugs may be helpful. To widen blood vessels and promote circulation, your doctor may prescribe:

  • Calcium channel blockers. These drugs relax and open up small blood vessels in the hands and feet. They decrease the frequency and severity of attacks in about two-thirds of the people who have Raynaud's. These drugs can also help heal skin ulcers on the fingers or toes. Examples include nifedipine (Procardia, Adalat), diltiazem (Cardizem, Dilacor), amlodipine (Norvasc), verapamil (Calan, Isoptin) and nicardipine (Cardene).
  • Alpha blockers. Some people find relief with these drugs, which counteract norepinephrine, a hormone that shrinks blood vessels. Examples include prazocin (Minipress) and doxazosin (Cardura).
  • Vasodilators. Some doctors prescribe a vasodilator (a drug that relaxes blood vessels), such as nitroglycerine cream. You put the cream on your fingers to help heal skin ulcers.
  • Other drugs. Some people with persistent symptoms may benefit by adding a drug called pentoxifylline (Trental), which improves circulation by making red blood cells more flexible as they pass through narrowed blood vessels.

You and your doctor may find that one drug works better for you than another. Often people with primary Raynaud's respond better to drugs than do those with the secondary form.

Some drugs for treating Raynaud's have side effects that may require you to stop taking them. A drug also mayu become less effective over time. Work with your doctor to find what works best for you.

Some drugs actually can make Raynaud's worse by leading to increased blood vessel spasm. 

Your doctor may recommend that you avoid taking:

  • Some over-the-counter cold and diet drugs. Examples include drugs that contain phenylpropanolamine (Contact, Dexatrim, Dimetapp, Sucrets) or pseudoephedrine (Actifed, Chlor-Trimeton, Sudafed).
  • Beta blockers. This class of drug, used to treat high blood pressure and heart disease, may worsen Raynaud's. Examples include metoprolol (Lopressor, Toprol), nadolol (Corgard) and propranolol (Inderal, Betachron).
  • Birth control pills. If you use birth control pills, switch to another method of contraception because these drugs affect your circulation and may make you more prone to attacks.

If you have questions about how to manage Raynaud's, contact your doctor. Your doctor may refer you to a doctor who specializes in treating Raynaud's.

Other Treatments

Sometimes, in cases of severe Raynaud's, approaches other than drugs may be an option.

  • Nerve surgery. Nerves called sympathetic nerves in your hands and feet control the opening and narrowing of blood vessels in your skin. Sometimes it's necessary in severe cases to cut these nerves. Through small cuts in the affected hands or feet, a doctor strips away these tiny nerves around the blood vessels. The surgery, called sympathectomy, may reduce the frequency and duration of attacks. It's not always successful.
  • Chemical injection. Doctors can inject chemicals to block sympathetic nerves in affected hands or feet. You may need to have the procedure repeated if symptoms come back or persist.
  • Amputation. Sometimes, doctors need to amputate a finger or toe in which the blood supply has been completely blocked and the tissue has developed gangrene. But this is rare.

Prevention

Raynaud's is a condition that you may need to manage for life once it develops. But there are ways to help prevent attacks:

  • Dress warmly outdoors. In winter, wear a hat, scarf, socks and boots, and mittens or gloves under mittens when you go outside. A hat is important because you lose a great deal of body heat through your head. Wear a coat with fairly snug cuffs, to prevent cold air from reaching your hands. Run your car heater for a few minutes before driving in cold weather.
  • Take precautions indoors. Wear socks. When taking food out of the refrigerator or freezer, wear gloves, mittens or oven mitts. Some people find it helpful to wear mittens and socks to bed during winter. Because air conditioning can trigger attacks, turning down the air conditioning may help prevent attacks. You also may find it helpful to use insulated drinking glasses.
  • Consider moving to a location with a milder climate. Moving to a warmer climate may help people with severe Raynaud's. However, Raynaud's can occur even in warmer climates when the temperature decreases.

A variety of steps can decrease Raynaud's attacks and help you feel better overall:

  • Quit smoking. Nicotine in cigarettes causes skin temperature to drop by constricting blood vessels, which may lead to an attack.
  • Control stress. Because stress may trigger an attack, learning to recognize and avoid stressful situations may help control the number of attacks.
  • Take care of your hands and feet. If you have Raynaud's, guard your hands and feet from injury. Don't walk barefoot. Take care of your nails to avoid injuring sensitive toes and fingertips. In addition, avoid wearing tight wristbands, rings or footwear that compress blood vessels in your hands or feet.
  • Avoid workplace triggers. Avoid tools that vibrate the hand.

If you are experiencing an attack of Raynaud's, the most important step is to warm your hands and feet or other affected areas of skin. The following can help you gently warm your fingers and toes:

  • Move to a warmer place
  • Place your hands under your armpits
  • Wiggle your fingers and toes
  • Make wide circles or windmills with your arms
  • Run warm (not hot) water over your fingers and toes

If a stressful situation triggers an attack, you can help stop the attack by getting out of the stressful situation and relaxing. If you're trained in biofeedback, you can use this technique along with warming your hands or feet in water to help lessen the attack.

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