by Derrick Garwood, Freelance Medical Writer and Editor

For most of us, cold hands and feet are a mild inconvenience when the temperature is close to freezing. For those with Raynaud's Phenomenon, however, an exaggerated response to cold means that temperatures as high as 10°C - 15°C can cause excruciating pain. One sufferer describes the three stages of a classical attack. "Fingers and toes go numb, quickly turning sheet white as all blood flow stops. Sometimes a dramatic line between the palm's rosy flesh and the white of bloodless fingers is marked. As the attack wanes, fingers turn blue as deoxygenated blood sluggishly returns. The end of the attack is even more painful as fingers flush deep red, burn and throb."

These symptoms, caused by sudden spasmodic contraction of the arterioles supplying blood to the fingers and toes, were first described by French physician Maurice Raynaud in 1862. Here is a good picture of the first stage of an attack.

General information about Raynaud's Phenomenon is available at sites run by the Medical College of Wisconsin and Med Help International. (For the latter, you may need to search under 'Raynaud's' from the home page.) Many more females than males have the condition; some authorities estimate that 20% of women experience it to some extent. Although the episodic attacks usually affect only the fingers and toes, they can extend to the lips, nose and ear lobes. They are usually brought on by lower than usual temperatures, or by physical or emotional stress.

Primary Raynaud's Phenomenon or Raynaud's Disease is idiopathic, i.e. there is no underlying cause or associated medical problem. Approximately 75% of cases are diagnosed in women between 15 and 40 years old. The condition can persist for many years without progressing.

Secondary Raynaud's Phenomenon arises as a result of another medical condition and is much less common, but tends to be more severe. Skin ulcers and gangrene are not unusual. Often, only both hands or both feet are affected. Connective tissue diseases are the most frequent cause; more than 85% of scleroderma patients exhibit Raynaud's Phenomenon and it may be the first symptom of their disease. For more information about this condition try the Scleroderma Research Foundation. Similarly, one third of systemic lupus erythematosus sufferers experience Raynaud's symptoms. Other causes include Sjögrens syndrome, polymyositis and obstructive arterial disease.

Certain occupations can increase vulnerability to Secondary Raynaud's Phenomenon. For example, Vibration White Finger is a prescribed industrial disease. It does not, as might be expected, result from over-gesticulation by delivery drivers of white vans, but is triggered by continuous use of vibrating hand machinery abnormal vascular responses are more severe in smokers than in non-smokers; smokers were almost twice as likely to have severe symptoms of vasoconstriction. For more detail about this study click here.

The cornerstone of diagnosis is a detailed medical history, and while it may be relatively easy to diagnose Raynaud's Phenomenon, it can be difficult to distinguish between the primary and secondary forms. The Clinical Physics Group at St Bartholomew's Hospital gives a very good account of non-invasive methods, including thermography, which may be used for this purpose. Nailfold capillaroscopy is particularly sensitive in differentiating functional abnormalities (often primary) from organic damage (secondary). In essence, this test involves examining the nailfolds under a microscope for enlarged or deformed capillaries. Useful blood tests include an antinuclear antibody test (ANA) to detect autoantibodies that attack nuclear material; a positive result indicates the presence of autoimmune or connective tissue disease. Some clinicians may also check the erythrocyte sedimentation rate (ESR) to detect any underlying pathology, although this test is less used than formerly.

In patients with Secondary Raynaud's Phenomenon it is important that the primary condition is treated. Other treatment is largely directed at preventing attacks and minimising their effects if they do occur. Sufferers should keep warm, try to avoid stress and emotional upsets, take regular exercise and, if smokers, stop the habit as soon as possible. If an attack does occur, the most important measure to take is to warm the hands and feet: for example, by running warm water over them.

Many people, especially those with Primary Raynaud's Phenomenon, have found that biofeedback training can help them decrease the number and severity of attacks. In a study at Wayne State University the frequency of symptoms decreased by between 66% and 92% after only 10 training sessions of 30 minutes each. Patients learned to control their skin temperature using an audible signal or light that was activated by temperature fluctuations.

German research has shown that acupuncture can produce a subjective improvement in symptoms. In this investigation the frequency of subjects' attacks reduced significantly, although the duration and severity of them did not.

When medication is required, many clinicians believe that calcium channel blockers such as nifedipine offer the safest and most effective treatment. These drugs, most frequently prescribed for hypertension, slow the movement of calcium into the cells of blood vessels, relaxing the smooth muscle and dilating the lumen. Other patients benefit from alpha-blockers, which are antagonists for noradrenaline.

Thoracic sympathectomy was previously reserved for the most severe cases, but today minimally invasive surgery can be carried out on an outpatient basis, through an incision only 3 mm in length. The website of Texan surgeon Dr David H. Nielson has been selected for this topic so that the tour can end with some rather good Quicktime videos of the procedure. You will have to be patient though, because the download is rather slow - except for those of you with broadband!

Do you have any comments on this article? Please contact Derrick directly at derrick@ecrivain.globalnet.co.uk.

The details presented here were accurate at the time of publication, but remember that information on the Web has a tendency to change without notice!

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