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Coping with Raynaud’s disease

In a nutshell, Raynaud’s disease is an exaggerated vascular response to cold or stress. Normally, our blood vessels narrow to preserve heat in our body’s core during cold weather, but in those with Raynaud’s, that response doesn’t just slow the amount of blood to fingers and toes, it is drastically reduced.

The result is fingers that turn shockingly white from loss of blood or blue from lack of oxygen. There is clear color demarcation between the affected and nonaffected skin. The fingers or toes may also feel cold and numb. When patients warm up, their fingers often turn bright red.

As the attack ends, throbbing and tingling may occur. An attack can last anywhere from less than a minute to several hours. It occurs most frequently in women and usually makes its first appearance between the ages of 16 and 25.

Diagnosing Raynaud’s disease
We usually diagnose Raynaud’s by listening carefully to how patients describe these attacks. Some physicians try to provoke an attack by dipping hands or feet in ice water, but we can usually determine if a patient is affected by their own description of the symptoms.

What’s more difficult initially is determining whether an individual is affected by primary or secondary Raynaud’s. It’s important to determine the type since secondary Raynaud’s is more serious and complex and may be the first clue of an underlying connective tissue disease such as scleroderma or lupus.

Although we don’t yet understand what causes Raynaud’s, there are some potential culprits that need to be ruled out. Some drugs can result in the same vasoconstrictive response, including cocaine, some over-the-counter cold medications and ergot drugs that are used to treat migraine headaches.

Raynaud’s phenomenon can also occur from damage to blood vessels from years of heavy smoking or experience with jarring machinery such as pile drivers.

Primary form more common
The primary form of Raynaud’s is by far the most common. There is no underlying medical condition associated with it and the symptoms are usually relatively mild.

Patients with secondary Raynaud’s, however, have a more aggressive form. Their episodes are more severe and may result in ulcerated tissue and in some cases, loss of fingers or toes.

One test we use to identify secondary Raynaud’s is called nailfold capillaroscopy. During this test, we put a drop of oil on the skin at the base of the patient’s fingernail. We then examine the tiny capillaries in this area under a microscope. If the capillaries are enlarged or deformed, the patient may have a connective tissue disease.

Lifestyle changes help
I usually encourage patients to begin by making lifestyle changes:

• Remove anything that may be aggravating the disease. Stop smoking; explore substitutes for medications that may be adding to the problem.
• Exercise, particularly vigorous aerobic exercise, helps many patients.
• Avoid unnecessary exposure to cold; always wear a hat, warm socks and mittens in cold weather.
• Many products designed for those who engage in cold-weather sports can be very helpful for Raynaud’s patients, including small chemical heating pouches that can be placed in pockets, mittens, boots or shoes.
• Air conditioning can trigger attacks. Turning down the air conditioning or wearing a sweater may help.
• Some people find it helpful to use insulated drinking glasses and to put on gloves before handling frozen or refrigerated foods.

These relatively simple measures are often enough to help those with primary Raynaud’s manage their condition.

Drug therapy
Those with secondary Raynaud’s and some others who need help with symptom control should discuss calcium channel blocker therapy with their physicians. The Annals of Internal Medicine study and others have shown a clear benefit—nearly two-thirds of patients are significantly helped by taking nifedipine.

Although the study comparing nifedipine and biofeedback indicated no improvement with biofeedback therapy, there have been some reports of success. Patients who have side effects such as headaches from nifedipine or who prefer a nondrug solution, might try biofeedback. Biofeedback is a process in which a patient is taught to gain voluntary control over a body process that’s typically nonvoluntary such as blood flow.

When to call a doctor
If you have distinct reversible color changes in your fingers or toes that are like those described above, you should see your doctor to rule out the presence of an underlying disease. If you have been diagnosed with Raynaud’s and develop unusual symptoms such as inflammation or sores or if you are not able to reverse a Raynaud’s attack after rewarming your extremities, call your doctor.

Dr. Evans is a rheumatologist at Yale-New Haven Hospital and an associate professor at the Yale School of Medicine.