When I was an ice skater, I would notice my hands change color to white, sometimes blue and then ultimately red after my time on the ice. Often, I would wear 2-3 pairs of gloves during my practice session because my hands would get so cold and painful. My core body temperature was always warm but I was always amazed at my finger’s reaction to the cold. Sometimes it would take 1 hour for my hands to defrost and get back to normal. I later learned in life that I was experiencing Raynaud’s phenomenon, which still happens to me.
What is Raynaud’s Phenomenon?
Raynaud’s phenomenon occurs when certain parts of the body (the extremities like your fingers and toes) experience color change as well as pain and numbness when there is exposure to cold temperature change or other triggers like smoking or stress. This reaction is a result of the narrowing of the small blood vessels (arteries) or vasoconstriction, due to the cold or other triggers. Ultimately there is a decrease in blood supply to the affected areas which may cause spasm of the blood vessels (vasospasm).
There are two types of Raynaud’s:
- Primary (Raynaud’s Disease) which doesn’t have a known cause. It is common in women and not usually serious.
- Secondary (Raynaud’s phenomenon)- Usually caused by an underlying disease. In my field, autoimmune diseases are a common reason to have this disorder. The underlying disease must be treated to help relieve symptoms.
In both cases, cold temperatures (even if mild changes) and stress can cause attacks in the hands and toes where little or no blood flows to these affected areas. The attacks rarely occur in the nose, ears, lips. I even experience this attack if I am in the freezer section in the supermarket or walking outside below 50 degrees Fahrenheit.
What happens in Raynaud’s?
Due to the reduced blood flow to the extremities, the skin may turn white (ischemia) and then blue (cyanosis) initially. As the blood flow returns after rewarming, the toes and fingers may become red again. The attacks may last minutes to hours like in my case. It is bothersome because these attacks can occur daily or weekly in some cases.
It may take up to 20 minutes or longer for circulation to return. Sometimes during this phase, the person may experience numbness, throbbing, burning or tingling. Over time with repetitive vasospasm from narrowing of the blood vessels, the small arteries can become thickened and really restrict blood flow. With Primary Raynaud, the whole hand may be affected while in other cases, one or two fingers or toes may be involved.
Causes For Secondary Raynaud’s:
- Autoimmune and Connective Tissue Diseases
- Rheumatoid Arthritis
- Sjorgren’s Syndrome
- Cryoglobulinemia and other blood disorders
- Thyroid Disease
- Arterial Diseases
- Atherosclerosis (plaque buildup in blood vessels supplying the heart)
- Primary Pulmonary Hypertension (high blood pressure in arteries supplying the lungs)
- Buerger’s Disease (an inflammatory disorder usually in male smokers that affect blood vessels in hand and feet causing inflammation)
- Chemical exposure (Vinyl chloride in plastics)
- Medications that can affect blood pressure or constrict the arteries
- Migraine medications containing ergotamine
- Certain over the counter allergy and cold therapies
- Specific cancer medications
- Beta-blockers- widely used for high blood pressure and to lower heart rate or after a heart attack
- Birth control pills
- Repetitive actions which cause damage to the nerves or arteries in the hands and feet (ex. using tools like drills)
- Hand and Foot injuries from surgery, trauma or frostbite.
Female gender, age after 30, family history, living in cold temperatures are all risk factors for Primary Raynaud’s. Age, secondary medical conditions, injuries, medications, and smoking can trigger Secondary Raynaud’s. STOP SMOKING TODAY!!
Your rheumatologist will take a careful history of your medical history of your symptoms and then perform a physical exam looking for color changes or any signs of prolonged limited blood supply like ulcers or other wounds at the finger and toe tips.
There will be testing for autoimmune diseases with blood work (Antinuclear antibody, RF, scl 70 ab, centromere ab, dsDNA ab, sm/RNP ab, SSA/SSB). Inflammation markers are also measured.
Nailfold Capillaroscopy may also be performed where the doctor places a drop of oil at the base of the fingernail and looks for specific blood vessel changes under a microscope or magnifying glass.
There is no cure for Raynaud’s disease or Raynaud’s phenomenon but symptoms may be improved or controlled and the number of attacks may be reduced. The goal is to prevent repetitive episodes of restricted blood supply to avoid the development of hand and feet ulcerations or sores and permanent injury. Sometimes dead tissue or gangrene can develop requiring amputation of the affected body part.
Lifestyle changes like smoking cessation, change in medications or occupation, reduction of emotional stress and removing yourself from cold temperatures definitely help.
- The winter season is not my favorite time of the year so I bundle myself with extra mittens, socks, thermal wear, and hats.
- Hand and foot warmers can be useful.
- I try not to work in air-conditioned rooms during the summer
- I do wear kitchen gloves if I am touching food in the freezer.
- Limit repetitive hand actions like typing if you can.
- Avoid medications as listed earlier in the blog. There are different types of high blood pressure medications, migraine and contraceptive methods that are available so discuss options with your doctor.
There are other therapies to treat Raynaud’s. Sometimes medications are needed in addition to lifestyle modifications.
MEDICATION OPTIONS INCLUDE:
1) Calcium Channel Blockers (Nifedipine, Amlodipine)- Blood pressure medications that help increase blood flow
2) Alpha-blockers- another type of blood pressure medication
3) Angiotensin receptor blockers- Blood pressure medication
4) Medications that increase blood flow and relax blood vessels ( Vasodilators) like Sildenafil, Nitroglycerin, Prostacyclins
5) Other medications like antidepressant medications (SSRIs), topical creams or cholesterol medications (statins) have also been used by some physicians to help improve symptoms.
For severe disease, there is a procedure to block the nerves in the hands or feet that can affect the artery supply to those areas. This can help prevent attacks.
During this wintertime, bundle up, pay attention to your toes and fingers! See a doctor if you have these symptoms!
Reference: American College of Rheumatology
Current Rheumatology textbook