Inside The Exam Room™ 12/11/2006
RAYNAUD’S SYNDROME: Part 2
By Mark Ombrellaro, MD
Secondary Raynaud’s syndrome is the condition where the symptoms of hand pain, numbness, and coolness resulting from abnormal spasm of the digital arteries of the fingers (while the major peripheral pulses remain intact) are due to an identifiable underlying disease process. The most common cause of secondary Raynaud’s syndrome is collagen vascular disease, in which over 90% of symptomatic patients are found to have scleroderma. Other types of collagen vascular disease causing secondary Raynaud’s syndrome include Lupus, Sjogren syndrome, CREST syndrome, polymyositis, and rheumatoid arthritis. Less common causes of secondary Raynaud’s syndrome are upper extremity atherosclerotic occlusive disease, including arterial emboli and Buerger’s disease (as the result of smoking); trauma from frostbite or the use of tools with lots of vibration (jack hammers); drugs including beta blockers and oral contraceptives; and other conditions such as thoracic outlet syndrome, hypothyroidism, and kidney disease. Patients with collagen vascular disease and Raynaud’s syndrome tends to have a more severe symptomatic picture including development of ulcers or gangrene of their digits. In patients with Raynaud’s symptoms, blood tests may be helpful in identifying potential secondary causes. The most common tests include a sedimentation rate (ESR) and antinuclear antibodies (ANA) and can assist in establishing a diagnosis of connective tissue disease. An elevated ESR is a general marker of a systemic (system wide) inflammatory process which is not specific for any one diagnosis while antinuclear antibodies are detected in conditions where the body’s immune system attacks its own cellular components. A homogeneous ANA pattern can be seen in lupus, a speckled pattern in scleroderma, and antibodies against specific components of the cell nucleus found in CREST syndrome. In patients with tissue loss or gangrene, performing an angiogram may be helpful in identifying other types of peripheral vascular disease and the extent of the vascular compromise.
The treatment of Raynaud’s syndrome is primarily directed towards reducing symptoms. Since the hands and feet normally undergo vasoconstriction as the response to conserving body heat in cold environments, treatment of Raynaud’s symptoms begins with keeping warm. Keeping the central core of the body warm means more heat will be transferred to the periphery and reduce or eliminate hand and feet symptoms. Patients are advised to dress in layers and wear gloves. It is not uncommon for my patients to be wearing sweaters and gloves in the spring or fall in order to keep their core temperature up. The bad news is that smoking, caffeinated beverages, and chocolate are known to cause vasoconstriction and their use should be minimized or avoided all together. In patients with very severe attacks; such as those developing recurrent severe pain, or complications such as thrombosis (clotting) of their digital circulation or ulceration of the tips of their digits; medical treatment with vasodilatation agents should also be considered. Most of the medications are commonly used for the treatment of high blood pressure or heart disease. Commonly used medications include calcium channel blockers (Nifedipine, Diltiazem, Felodipine, Isradipine) and sympathetic blocking agents (Prazosin, Nitro ointment). I also use an antiplatelet agent (aspirin) in order to reduce the chance of intravascular thrombosis during the low flow period of the vasospastic attack. Nifedipine tends to be used most often and can reduce the frequency, duration, and magnitude of Raynaud’s attacks. It can also been used successfully to treat symptoms of Raynaud’s in children. Side effects of Nifedipine include headache, leg edema, and of course lowering the blood pressure. I have found that many of the young women treated with calcium channel blockers often complain of feeling weak and tired as the result of the reduced blood pressure from medical therapy. While most get used to it over time, there are some that may require a reduced medication dose and the ability to balance treatment with persistent symptoms, on an individualized basis. Treatment of secondary Raynaud’s syndrome also includes addressing the primary underlying disease condition as well.