Raynaud's

Question 1

What is the epidemiology and aetiology of Raynaud’s?

Answer 1

F>M at 3-12.5%:6-20%

Prevalence is higher in colder climates

Risk factors:

• FHx, Emotional stress, Oestrogen exposure in women
• Smoking, hand-arm vibration syndrome in men
• Also migraines, arterial disease e.g. vasculitis, beta-blockers, previous frostbite

89% = primary; 11% secondary to an underlying cause

Question 2

What is the pathophysiology of Raynaud’s?

Answer 2

An exaggerated vasospastic response to a stimulus:

• Paroxysmal vasospastic and subsequent vasodilatory chain of events affecting peripheral arterioles, usually in the hands and feet
• It commonly occurs as a response to cold exposure but may also be precipitated by emotional turmoil
• The process may occur as a primary entity or secondary to other disease processes

Question 3

How does Raynaud’s present?

Answer 3

3 stages:

• Pallor - WHITE distal portion of 1+ digits; thumb usually spared; clear demarcation line between affected and normal skin
• Numbness or pain in digits then cyanosis/BLUE of the digit
• Hyperaemic phase - digit becomes RED and feels warm

Variation in the time spent in/degree of manifestation of each phase

Question 4

How do you clinically investigate Raynaud’s?

Answer 4

History:

• Ask about associated symptoms (migraine, recent joint/muscle pain, rashes, infection, weight loss etc)
• Occupational Hx - vibrating tools as a risk
• Medication Hx
• Ever had frostbite?

Examination:

• Will not often find anything as patients rarely present during an episode
• Any arrhythmias/murmurs (embolic disease)?
• Signs of SLE or systemic sclerosis?
• Hepatosplenomegaly? Lymhpadenopathy?

Classically a well, young woman with unremarkable examination

Question 5

What formal investigations do you use for Raynaud’s?

Answer 5

FBC
Antinuclear antibodies - underlying inflammatory disease
CRP/ESR/plasma viscosity

Possible U+E, LFT, TFT

Plasma glucose - DM?

Refer patients with suspected secondary Raynaud’s for capillaroscopy (if available)

Other examples of tests are:
Infrared thermography, laser Doppler flowmetry, portable radiometry and digital plethysmography are

Question 6

How do you differentiate primary from secondary Raynaud’s?

Answer 6

Primary:
- Younger, female, genetic component (30% have 1st degree relative), no signs of underlying disease
- Normal ESR, negative
antineutrophil Abs

Secondary:

• Older, signs of underlying disease
• Raised ESR, positive antineutrophil Abs

Question 7

What is the personal/general management for Raynaud’s?

Answer 7

Stop smoking

Avoid cold exposure + take precautionary measures e.g. heated mittens/gloves

Change DIY/occupation habits if vibration is causative

Question 8

What treatments exist for Raynaud’s?

Answer 8

If secondary, manage cause; these are more likely to be problematic (ulceration, scarring or gangrene)

Topical:
- GTN - applied to dorsum of finger reduces severity (but not duration or frequency) of attacks

Systemic:
- CCBs e.g. nifedipine = relaxation of vascular smooth muscle cells leading to vasodilatation; reduce frequency and duration but not severity of attacks

Surgical:

• Only for severe and disabling symptoms
• Includes arterial reconstruction, peripheral sympathectomy, embolectomy and ulcer debridement etc.