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| | __NOTOC__ |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
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| {{Raynaud's phenomenon}} | | {{Raynaud's phenomenon}} |
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| '''Editors-In-Chief:''' Asghar Fakhri, M.D., Duane S. Pinto, M.D. and C. Michael Gibson, M.S., M.D. | | '''Editors-In-Chief:''' Asghar Fakhri, M.D., Duane S. Pinto, M.D. and C. Michael Gibson, M.S., M.D. |
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| == Overview == | | ==[[Raynaud's phenomenon overview|Overview]]== |
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| '''Raynaud's phenomenon''' (RAY-noz), in [[medicine]], is a [[vasospasm|vasospastic]] disorder causing discoloration of the [[finger]]s, [[toe]]s, and occasionally other extremities, named for French physician [[Maurice Raynaud]] (1834 - 1881). The cause of the phenomenon is unknown, but [[emotional stress]] and cold are classically triggers, and the discoloration follows a characteristic pattern in time: white, blue and red. It comprises both '''[[Raynaud's disease]]''' (''primary Raynaud's''), where the phenomenon is [[idiopathic]], and '''Raynaud's syndrome''' (''secondary Raynaud's''), where it is secondary to something else.
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| == Incidence ==
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| The phenomenon is more common in women than men, with the [[Framingham Heart Study|Framingham Study]] finding that 5.8% of men and 9.6% of women suffered from it.
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| == Epidemiology ==
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| There is a familial component to primary Raynaud's, and presentation is typically before 30. [[tobacco smoking|Smoking]] worsens frequency and intensity of attacks, and there is a hormonal component. Sufferers are more likely to have [[migraine]] and [[Angina pectoris|angina]] than controls.
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| == Associated Conditions ==
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| Secondary Raynaud's has a number of associations:
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| * [[Connective tissue disorder]]s:
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| ** [[scleroderma]]
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| ** [[Systemic lupus erythematosus]]
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| ** [[rheumatoid arthritis]]
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| ** [[Sjögren's syndrome]]
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| ** [[dermatomyositis]]
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| ** [[polymyositis]]
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| * [[Eating disorder]]s
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| ** [[Anorexia Nervosa]]
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| * Obstructive disorders
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| ** [[atherosclerosis]]
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| ** [[Buerger's disease]]
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| ** [[aneurysm|subclavian aneurysm]]s
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| ** [[thoracic outlet syndrome]]
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| * [[Drugs]]
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| ** [[Beta-blocker]]s
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| ** [[cytotoxic drug]]s - particularly [[chemotherapy|chemotherapeutics]] and most especially [[bleomycin]]
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| ** [[cyclosporin]]
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| ** [[ergotamine]]
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| ** [[sulfasalazine]]
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| * Occupation
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| ** jobs involving vibration, particularly drilling
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| ** exposure to [[vinyl chloride]]
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| ** exposure to the cold (e.g. by working packing frozen food)
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| * Others
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| ** [[hypothyroidism]]
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| ** [[cryoglobulinemia]]
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| ** [[Cancer|malignancy]]
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| ** [[Complex regional pain syndrome|reflex sympathetic dystrophy]]
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| ** [[Acromegaly]]
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| ** After blunt [[trauma]]s
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| ** After surgery
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| ** [[Arsenic]]
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| ** [[Arterenol]]
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| ** [[Arteriosclerosis Obliterans]]
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| ** [[Arteriovenous Fistula]]
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| ** Arthrosis of cervical spine
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| ** [[Axillary vein]] [[thrombosis]]
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| ** [[Carpal tunnel syndrome]]
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| ** [[Cervical rib]]
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| ** [[Cirrhosis]]
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| ** [[Cold agglutinins]]
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| ** [[Costoclavicular Syndrome]]
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| ** [[Clonidine]]
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| ** [[Cryoglobulinemia]]
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| ** [[Cytotoxic drug]]s
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| ** [[Dermatomtositis]]
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| ** [[Dysproteinemia]]
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| ** [[Ergotamine]]
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| ** [[Heavy metals]]
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| ** [[Hemiplegia]]
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| ** [[Hormonal contraceptives]]
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| ** [[Hypothenar Hammer Syndrome]]
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| ** [[Lead]]
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| ** [[Leukemia]]
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| ** [[Lupus Erythematosus]]
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| ** [[Mixed connective tissue disorders]]
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| ** [[Multiple Sclerosis]]
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| ** [[Neoplasm]]
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| ** [[Peripheral Neuropathy]]
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| ** [[Peripheral emboli]]
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| ** [[Poiliomyelitis]]
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| ** [[Polyarteritis Nosdosa]]
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| ** [[Polycythemia Vera]]
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| ** [[reflex sympathetic dystrophy|Post-traumatic reflex sympathetic dystrophy]]
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| ** [[Propranolol]]
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| ** [[Rheumatoid Arthritis]]
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| ** [[Scalenus-anticus Syndrome]]
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| ** [[Scleroderma]]
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| ** [[Scoliosis]]
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| ** [[Sjorgen's Syndrome]]
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| ** [[Spinal tumor]]
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| ** [[Sulfasalazine]]
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| ** [[Syringomyelia]]
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| ** [[Thallium]]
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| ** [[Thromboangitis obliterans]]
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| ** [[Thoracic outlet syndrome]]
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| ** Vibrations
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| ** [[Wegener's Granulomatosis]]
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| It is important to realise that Raynaud's can ''herald'' these diseases by periods of more than 20 years in some cases, making it effectively their first presenting symptom. This can be the case in the [[CREST syndrome]], of which Raynaud's is a part.
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| == Diagnosis ==
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| === Physical Examination ===
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Raynaud's Phenomenon (Scleroderma).jpg|Raynaud's Phenomenon
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| </gallery>
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| </div>
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| == Complete List of Differential Diagnoses ==
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| In alphabetical order <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:144</ref><ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:310-311</ref>
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| * [[Acromegaly]]
| | ==[[Raynaud's phenomenon pathophysiology|Pathophysiology]]== |
| * After blunt traumas
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| * After surgery
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| * [[Arsenic]]
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| * [[Arterenol]]
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| * [[Arteriosclerosis Obliterans]]
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| * [[Arteriovenous Fistula]]
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| * [[Arthrosis of cervical spine]]
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| * [[Axillary vein thrombosis]]
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| * [[Carpal tunnel syndrome]]
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| * [[Cervical rib]]
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| * [[Cirrhosis]]
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| * [[Cold agglutinins]]
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| * [[Costoclavicular Syndrome]]
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| * [[Clonidine]]
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| * [[Cryoglobulinemia]]
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| * [[Cytotoxic drug]]s
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| * [[Dermatomtositis]]
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| * [[Dysproteinemia]]
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| * [[Ergotamine]]
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| * [[Heavy metal]]s
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| * [[Hemiplegia]]
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| * [[Hormonal contraceptives]]
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| * [[Hypothenar Hammer Syndrome]]
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| * [[Lead]]
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| * [[Leukemia]]
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| * [[Lupus Erythematosus]]
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| * [[Mixed connective tissue disorder]]s
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| * [[Multiple Sclerosis]]
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| * [[Neoplasm]]
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| * Percussions
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| * [[Peripheral Neuropathy]]
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| * [[Peripheral emboli]]
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| * [[Poiliomyelitis]]
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| * [[Polyarteritis Nosdosa]]
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| * [[Polycythemia Vera]]
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| * [[reflex sympathetic dystrophy|Post-traumatic reflex sympathetic dystrophy]]
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| * [[Propranolol]]
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| * [[Rheumatoid Arthritis]]
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| * [[Scalenus-anticus Syndrome]]
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| * [[Scleroderma]]
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| * [[Scoliosis]]
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| * [[Sjorgen's Syndrome]]
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| * [[Spinal tumor]]
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| * [[Sulfasalazine]]
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| * [[Syringomyelia]]
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| * [[Thallium]]
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| * [[Thromboangitis obliterans]]
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| * [[Thoracic outlet syndrome]]
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| * Vibrations
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| * [[Vinyl chloride poisioning]]
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| * [[Wegener's Granulomatosis]]
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| == Symptoms == | | ==[[Raynaud's phenomenon causes|Causes]]== |
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| The condition causes painful, pale, cold extremities. This is often distressing, impinges on quality of life, and is potentially dangerous
| | ==[[Raynaud's phenomenon differential diagnosis|Differentiating Raynaud's phenomenon from other Diseases]]== |
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| Unilateral Raynaud's, or that which is present only in the hands or feet, is almost certainly secondary, as primary Raynaud's is a systemic condition. However, a patient's feet may be affected without his realizing it.
| | ==[[Raynaud's phenomenon epidemiology and demographics|Epidemiology and Demographics]]== |
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| In [[pregnancy]], this sign normally disappears due to increased surface [[blood flow]].
| | ==[[Raynaud's phenomenon risk factors|Risk Factors]]== |
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| === Investigations === | | ==[[Raynaud's phenomenon screening|Screening]]== |
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| A careful [[medical history|history]] will often reveal whether the condition is primary or secondary. Once this has been established, investigations are largely to identify or exclude possible secondary causes.
| | ==[[Raynaud's phenomenon natural history|Natural History, Complications and Prognosis]]== |
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| * Digital artery pressure: pressures are measured in the digital arteries before and after cooling the hands. A drop of 15 mmHg or more is diagnostic.
| | == Diagnosis == |
| * [[Doppler ultrasound]]: to assess flow
| | [[Raynaud's phenomenon history and symptoms| History and Symptoms]] | [[Raynaud's phenomenon physical examination | Physical Examination]] | [[Raynaud's phenomenon laboratory findings | Laboratory Findings]] | [[Raynaud's phenomenon other imaging findings|Other imaging findings]] | [[Raynaud's phenomenon other diagnostic studies|Other diagnostic studies]] |
| * [[Full blood count]]: this can reveal a normocytic [[anaemia]] suggesting the [[anaemia of chronic disease]] or [[renal failure]]
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| * [[Blood test|Urea & Electrolytes]]: this can reveal renal impairment
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| * [[Thyroid function tests]]: this can reveal [[hypothyroidism]]
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| * An [[autoantibody]] screen, tests for [[rheumatoid factor]], [[Erythrocyte sedimentation rate]] and [[C-reactive protein]], which may reveal specific causative illnesses or a generalised inflammatory process
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| * Nail fold vasculature: this can be examined under the microscope
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| == Laboratory Findings == | | ==Treatment== |
| | | [[Raynaud's phenomenon medical therapy|Medical therapy]] | [[Raynaud's phenomenon primary prevention|Primary prevention]] | [[Raynaud's phenomenon secondary prevention|Secondary prevention]] | [[Raynaud's phenomenon cost-effectiveness of therapy|Financial costs]] | [[Raynaud's phenomenon future or investigational therapies|Future therapies]] |
| * Labs include:
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| :* [[CBC]] with differential
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| :* [[TSH]]
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| :* [[Hepatitis]]
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| :* [[Creatine phosphokinase]]
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| :* [[ANA]]
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| :* [[ESR]]
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| :* [[Rheumatoid factor]]
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| === Autoantibody Testing ===
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| * Anti-double stranded DNA and anti - Sm
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| * Anti - Sjögren's syndrome
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| * Anti - CREST syndrome
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| * Anti - ribonucleoprotein
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| * Anti - Scl 70
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| * ANCA
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| == Treatment ==
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| Treatment options are dependent on the type of Raynaud's present. Raynaud's syndrome is treated primarily by addressing the underlying cause, but includes all options for Raynaud's disease as well. Treatment of primary Raynaud's focuses on avoiding triggers:
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| * Avoidance of any environmental triggers, e.g. cold, drilling, etc. (although emotional stress is a recognised trigger, it tends to be impossible to consciously avoid).
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| * Warm clothing for the extremities such as mittens or HeatBands
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| * Hormone regulation and assessment of the type of [[hormonal contraception]] used, if any. Contraception which is low in [[estrogen]] is preferable, and the [[progesterone only pill]] is often prescribed.
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| * Smoking cessation.
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| * Drug treatment is normally with a [[calcium channel blocker]], frequently [[nifedipine]] to prevent arterioconstriction. It has the usual side effects of headache, flushing, and ankle [[edema]], and patients often stop treatment, preferring the symptoms of Raynaud's to the symptoms of the drug.
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| * The extract of the [[Ginkgo biloba]] leaves (Egb 761, 80mg) reduces symptoms in two weeks.
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| * There is some evidence that [[Angiotensin II receptor antagonist]]s (often [[Losartan]]) reduce frequency and severity of attacks.
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| * In intractable cases, [[sympathectomy]] and infusions of [[prostaglandin]]s, e.g. [[prostacyclin]], may be tried, with [[amputation]] in exceptionally severe cases.
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| * Alpha-1 adrenergic blockers such as prazosin can be used to control Raynaud's vasospasms under supervision of a health care provider.
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| * In a study published in the November 8, 2005 issue of ''Circulation'', [[sildenafil]] (Viagra) improved both microcirculation and symptoms in patients with secondary Raynaud's phenomenon resistant to vasodilatory therapy. The authors, led by Dr Roland Fries (Gotthard-Schettler-Klinik, Bad Schönborn, Germany), report: "In the present study, capillary blood flow was severely impaired and sometimes hardly detectable in patients with Raynaud's phenomenon. Sildenafil led to a more than 400% increase of flow velocity."
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| * Two separate gels combined on the fingertip (somewhat like two-part [[epoxy]], they cannot be combined before use because they will react) increased blood flow in the fingertips by about three times. One gel contained 5% sodium nitrite and the other contained 5% ascorbic acid. The milliliter of combined gel covered an area of ~3 cm². The gel was wiped off after a few seconds. Tucker, A.T. et al., ''The Lancet'', Vol. 354, November 13, 1999, pp..
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| == See also == | | == See also == |
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| * [[CREST syndrome]] | | * [[CREST syndrome]] |
| * [[Circulatory system]] | | * [[Circulatory system]] |
