How can Raynaud’s phenomenon be managed in primary care?

Raynaud’s phenomenon (RP) is a common vascular disorder. Its main characteristic is the episodic vasospasm of the small arteries, typically in the fingers and toes. This leads to colour changes (pallor, cyanosis, and erythema) and symptoms such as pain, numbness, or tingling.

The disorder can be primary (idiopathic) or secondary to underlying conditions such as connective tissue diseases. Effective management in primary care involves:

• Accurate diagnosis,
• Patient education,
• Lifestyle modifications, and
• Appropriate pharmacological interventions when necessary.

This article is a step-by-step guide for managing Raynaud’s phenomenon in primary care.

How to diagnose and assess Raynaud’s phenomenon

As mentioned, the typical symptoms of Raynaud’s phenomenon include episodic colour changes (e.g. from white to blue to red) in response to cold or stress. These changes are often accompanied by pain, numbness, or tingling. The affected areas include primarily fingers and toes, but may also involve the nose, ears, or lips. The usual triggers are cold exposure, emotional stress, or vibration.

How to differentiate primary vs. secondary Raynaud’s phenomenon

Primary Raynaud’s phenomenon typically develops before the age of 30. It is characterised by the symmetric involvement of fingers, with no history of tissue injury, ulceration, or gangrene and normal nailfold capillaries on examination.

Usually, there are no signs of underlying connective tissue disease, and the autoantibodies (ANA) are negative.

With secondary Raynaud’s the onset is usually after 30 years of age. The symptoms are severe and asymmetric. Typically, there is a history of digital ulcers, pitting scars, or gangrene. Dilated loops, haemorrhages, and other abnormalities affecting the nailfold capillaries may be present.

There can also be signs of underlying connective tissue disease, such as scleroderma, rheumatoid arthritis, or lupus, and the autoantibodies (ANA, anti-centromere, anti-Scl-70) are positive with secondary RP.

Aside from nailfold capillaroscopy and autoantibody testing, primary care doctors should also consider CBC, ESR, CRP, and thyroid function tests, if secondary Raynaud’s is suspected.

How patient education and lifestyle modifications can help

The key advice for patients presenting to primary care is to avoid triggers. This means minimising exposure to low temperatures and avoiding sudden temperature changes by wearing gloves, warm clothing, and using hand warmers. It may also help to reduce emotional stress, quit smoking, and exercise regularly.

Proper hand and foot care is essential. It is important to protect digits from trauma or injury and keep the skin moisturised to prevent cracking.

Pharmacological management of Raynaud’s phenomenon

Pharmacological treatment is indicated for patients with frequent or severe episodes, or those at risk of digital ulcers or tissue damage.

First-line therapy includes calcium channel blockers (CCBs), such as Nifedipine (30–60 mg extended-release daily). Quality alternatives include Amlodipine or diltiazem.

These medications can produce side effects that require monitoring, including headaches, flushing, and ankle oedema.

Second-line therapy, when CCBs are ineffective or contraindicated, can include Phosphodiesterase-5 inhibitors, such as Sildenafil (20 mg three times daily) or tadalafil.

Topical nitrates, such as glyceryl trinitrate ointment, can also be applied to affected areas (may cause headaches). For severe and refractory cases, other therapies may be necessary. Depending on the symptoms, these may include:

• Prostacyclin analogues: Iloprost (intravenous) for severe digital ischemia.
• Endothelin receptor antagonists: Bosentan for recurrent digital ulcers.
• Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine may be considered for vasodilation.

Regular monitoring and follow-up of Raynaud’s phenomenon patients are essential for the effective management of the disorder.

Raynaud’s phenomenon is a condition that can be successfully managed by primary care doctors with additional education in general dermatology. A comprehensive treatment plan should include patient education, lifestyle modifications, and appropriate use of medications.

Early recognition of secondary Raynaud’s phenomenon and timely referral to secondary care are crucial to prevent complications and address underlying conditions.

– Dr Rosmy De Barros

For further information on this topic, you may be interested to learn more about the HealthCert online Professional Diploma program in General Dermatology.

See further articles, webinars, videos, podcasts, research, and more in primary care General Dermatology.

References

• Temprano KK. A Review of Raynaud's Disease. Mo Med. 2016;113(2):123-126.
• Smith V, Ickinger C, Hysa E, et al. Nailfold capillaroscopy. Best Pract Res Clin Rheumatol. 2023;37(1):101849. doi:10.1016/j.berh.2023.101849
• Koulouri V, Nezos A, Marketos N, et al. The Role of Novel Autoantibodies in the Diagnostic Approach and Prognosis of Patients with Raynaud's Phenomenon. Mediterr J Rheumatol. 2020;31(4):427-429. Published 2020 Dec 28. doi:10.31138/mjr.31.4.427
• Ennis H, Hughes M, Anderson ME, Wilkinson J, Herrick AL. Calcium channel blockers for primary Raynaud's phenomenon. Cochrane Database Syst Rev. 2016;2(2):CD002069. Published 2016 Feb 25. doi:10.1002/14651858.CD002069.pub5
• Maltez N, Maxwell LJ, Rirash F, et al. Phosphodiesterase 5 inhibitors (PDE5i) for the treatment of Raynaud's phenomenon. Cochrane Database Syst Rev. 2023;11(11):CD014089. Published 2023 Nov 6. doi:10.1002/14651858.CD014089
• Curtiss P, Schwager Z, Cobos G, Lo Sicco K, Franks AG Jr. A systematic review and meta-analysis of the effects of topical nitrates in the treatment of primary and secondary Raynaud's phenomenon. J Am Acad Dermatol. 2018;78(6):1110-1118.e3. doi:10.1016/j.jaad.2018.01.043