Key learning points:
– Recognising a Raynaud’s attack and triggers
– Being able to support patients with practical advice and support
– Signpost patients to appropriate therapy or medication if required, and understand when patients require a further assessment at a specialist centre
Raynaud’s phenomenon was first described by a French physician; Maurice Raynaud in 1862. It is an episodic circulatory condition where there is an over sensitivity to the cold or emotion or stress.
This is due to extreme vasospasm of the microvascular system in the hands and feet. Its classical presentation is triphasic colour change that occurs in the extremities during an attack. The fingers usually (but not always) go white (ischaemia) then blue (deoxygenation) and finally red (reperfusion) (1) other peripheral areas such as the nose, lips, ears and nipples can also be affected.
Raynaud’s phenomenon is common, particularly among women. Its exact prevalence is not known but it is thought to affect 3-20% of the adult population globally and as many as 10 million sufferers in the UK. (2) A GP based study reported that 19% of patients attending surgeries had Raynaud’s phenomenon. (3)
Signs and triggers
Alongside the above ‘hallmark’ colour changes that occur with Raynaud’s phenomenon there are other symptoms to consider. Pain is a commonly reported problem; numbness, tingling and a ‘pins and needles’ sensation are also frequently mentioned. This can make day-to-day life for sufferers difficult. Going to the supermarket especially in the refrigerated or freezer aisles can be a real challenge, turning keys in locks on a cold day, putting hands on a cold steering wheel or holding a cold glass of drink on a summer day all present hurdles that are often taken for granted. The increasing prevalence of air conditioning can also be a test of endurance.
The severity of these symptoms can vary from person to person and the length of time the attack lasts is also changeable from a few minutes to several hours.
Raynaud’s phenomenon has two subsets: primary and secondary. Primary Raynaud’s phenomenon is by far more common and can develop at any age spontaneously and is without any underlying condition being present.
Patients who have Raynaud’s secondary to an underlying disease, such as scleroderma, will often experience more severe symptoms such as fingertip ulceration and gangrene. (4)
A routine blood test looking for anti-nuclear antibodies (ANA) or blood vessel changes around the nail bed (nailfold capillaroscopy) can help to determine whether any underlying condition is likely to be present. (5)
Patients with secondary Raynaud’s should always be under the care of a specialist centre for further assessment and care.
Current best treatment and management
Treatment for Raynaud’s largely falls into three categories:
– Self-management and conservative measures.
– Natural therapies (e.g. vitamins and supplements).
Some patients will only need to use one of these measures, where as others will need to regularly use all three depending on the severity of their symptoms.
Everyone has their own way of coping with Raynaud’s but there are some suggestions that healthcare professionals can share with patients to support them.
Prevention is key; once a Raynaud’s sufferer is cold they can take a long time to warm up again, therefore they should always be prepared and leave plenty of time to get ready.
Layering thin clothes is more effective than one thick jumper or coat as this allows air to be trapped within the layers aiding warmth.
Thermal underwear, vests, long sleeve t-shirts with a jumper and an insulted/windproof coat, hat, scarf and gloves are all necessary to fight the cold.
Thermal or insulated boots and gloves are useful too and necessary for many patients. Their boots need to be comfortable, well lined and waterproof if possible. Patients will often buy a size or half size bigger to accommodate thick thermal socks too.
Hand warmers, which are now widely available to sit inside gloves or to have one in each coat pocket can be helpful especially if patients are going to be outside for a few hours. Foot and body warmers are also available.
Silk thermal liners from outdoor and camping shops are useful to put on first with thicker gloves over the top to give an extra layer of insulation without adding bulk. It is then easier to take off the thicker glove to get out a purse, wallet or keys with the thinner glove still on so the hand is not exposed to the cold.
Laying clothes on the radiator to warm up before putting
them on, or placing socks and gloves under a hairdryer can also be helpful.
If it is practical to do so, it can be useful to start the car a few minutes before going out to put the heater on. Gloves are essential for driving in the winter due to the cold steering wheel, gearstick and handbrake.
As far as possible it is very important to keep the temperature around a Raynaud’s sufferer constant, especially between rooms at home. Although difficult situations are not predictable patients do need to be reminded that stress and emotional anxiety can also trigger attacks.
It also should be mentioned to those who suffer from Raynaud’s that smoking and excessive caffeine can make Raynaud’s symptoms much worse. They need to be supported to give up and signposted to appropriate local help.
There is some evidence that has implied certain vitamins and supplements can help with circulation.
These are gamolenic acid (GLA) – this is available in its own supplement form from health food shops, or it is also present in high doses of evening primrose oil and starflower oil capsules.
Maxepa (five caps twice a day) or omacor (four caps a day) from a GP on prescription. These are high dose omega-3 fatty acid compounds as outlined in the British National Formulary. (6,7)
The role of antioxidant support has also been discussed, particularly around vitamin C and E. A review supporting the use of micronutrient antioxidants and that the combination of vitamins C and E may help tissue damage imposed by Raynaud’s and, more importantly, for patients with secondary Raynaud’s. (8)
The use of high dose gingko biloba in Raynaud’s has also been explored as another natural therapy by Muir et al. (9) Their study showed a reduction in Raynaud’s attacks per day, however, it was a small study and was recommended future work should be undertaken to evaluate this further.
Anecdotal evidence from the Royal Free London NHS Foundation Trust also includes the use of fresh ginger or ginger supplements.
Dietary changes including increasing foods such as, garlic, chilli, ginger in cooking can also help due their known warming properties. Some patients have found a combination of any of the above to work well.
The efficacy of these approaches varies from person to person but Raynaud’s sufferers often begin with a natural therapy to see if it is helpful before moving on to medication.
A commonly prescribed medication for Raynaud’s phenomenon is nifedipine as it is stipulated in the BNF for this use. However, other agents are also useful including other calcium channel blockers such as diltiazem.
Evidence from Dziadzio et al suggested losartan was beneficial compared to nifedipine, and that clinical benefit was greater in patients with primary Raynaud’s. (10)
The use of fluoxetine was studied by Coleiro et al suggesting that Fluoxetine was beneficial compared to nifedipine and was generally well tolerated. (4) Although results showed that the response to treatment was variable, their results concluded that the greatest benefit was in female patients with primary Raynaud’s.
Both of the above studies suggested larger trials would be warranted to ascertain further clinical efficacy and tolerability.
In severe cases of primary and secondary Raynaud’s phenomenon an iloprost infusion may be necessary. This is a potent vasodilator, which opens up the blood vessels allowing the blood to circulate to the peripheral areas more easily. This is usually given in a day case setting over five days.
Overall, Raynaud’s for many patients can be difficult to manage, but with the above approaches patients can often find one or several agents or lifestyle changes that are helpful for them. This often takes time and the need to try several agents and nursing practice is ideally placed to support this process. This also should include the provision of appropriate and up to date information as well as emotional and practical support.
For further information the UK has two charities to help patients:
Scleroderma Society– www.sclerodermauk.org
Raynaud’s & Scleroderma Association– www.raynauds.org.uk
1. Herrick AL. Pathogenesis of Raynaud's phenomenon. Rheumatology Oxford, England. 2005;44(5):587-96.
2. Bakst R, Merola JF, Franks AG, Jr., Sanchez M. Raynaud's phenomenon: pathogenesis and management. Journal of the American Academy of Dermatology. 2008;59(4):633-53.
3. Silman A, Holligan S, Brennan P, Maddison P. Prevalence of symptoms of Raynaud's phenomenon in general practice. British Medical Journal (Clinical research ed). 1990;301(6752):590-2.
4. Coleiro B, Marshall SE, Denton CP, Howell K, Blann A, Welsh KI, et al. Treatment of Raynaud's phenomenon with the selective serotonin reuptake inhibitor fluoxetine. Rheumatology Oxford, England. 2001;40(9):1038-43.
5. Herrick AL, Cutolo M. Clinical implications from capillaroscopic analysis in patients with Raynaud's phenomenon and systemic sclerosis. Arthritis and rheumatism. 2010;62(9):2595-604.
6. Royal Pharmaceutical Society. BNF 69 : British national formulary 2015.
7. Belch JJ, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. The American journal of clinical nutrition. 2000;71(1 Suppl):352s-6s.
8. Simonini G, Pignone A, Generini S, Falcini F, Cerinic MM. Emerging potentials for an antioxidant therapy as a new approach to the treatment of systemic sclerosis. Toxicology. 2000;155
9. Muir AH, Robb R, McLaren M, Daly F, Belch JJ. The use of Ginkgo biloba in Raynaud's disease: a double-blind placebo-controlled trial. Vascular medicine London, England. 2002;7(4):265-7.
10. Dziadzio M, Denton CP, Smith R, Howell K, Blann A, Bowers E, et al. Losartan therapy for Raynaud's phenomenon and scleroderma: clinical and biochemical findings in a fifteen-week, randomized, parallel-group, controlled trial. Arthritis and rheumatism. 1999;42(12):2646-55.
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