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Overview |
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Definition |
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According to the U.S. National Heart, Lung, and Blood Institute, Raynaud's
phenomenon is characterized by episodic vasospastic attacks resulting in digital
ischemia. Fingers are most often affected, rarely toes. Sudden spasmodic
contractions of arterioles occur when patient is exposed to cold or becomes
stressed; episodes are intermittent and may last minutes or hours. Approximately
5% to 10% of the United States population is affected, with women being affected
five times more often than men. It occurs usually between the ages of 20 to 40
in women and later in life for men. An estimated 80% to 90% of women with
scleroderma have Raynaud's phenomenon. The two major subtypes are:
- Raynaud's disease or syndrome (primary/idiopathic), in which cases
persist for more than two to three years without evidence of an associated
disease. Progressive disease—spasms become more
frequent and more severe.
- Secondary Raynaud's phenomenon, a less common form resulting from
underlying disease, such as connective tissue disease. Increased morbidity and
poorer prognosis.
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Etiology |
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Biologic factors (e.g., abnormalities in the adrenergic receptor);
psychodynamic influences (e.g., stress); underlying disease (e.g., systemic
lupus erythematosus) |
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Risk Factors |
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- Cigarette smoking
- Age in women (onset primarily between the ages of 20 and 40)
- Occupation (using vibrating tools like chainsaws and jackhammers)
- Pharmaceuticals (including ergot preparations) methysergide,
beta-adrenergic receptor antagonists, chemotherapeutic agents such as bleomycin,
vinblastine, cisplatin; and some over-the-counter cold medications and
prescription narcotics
- Existing autoimmune or connective tissue disorder
- Electric shock injury
- Previous frostbite
- Repeated physical stress (such as that resulting from typing or piano
playing)
- Primary pulmonary hypertension
- Exposure to cold
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Signs and Symptoms |
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- Changes in skin color in the fingers or toes and sometimes in the
nose, legs, or earlobes (may occur in three phases: pallor, cyanosis,
rubor)
- Throbbing, tingling, numbness, and pain
- Atrophy of the terminal fat pads
- Gangrenous ulcers near fingertips
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Differential
Diagnosis |
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- Rheumatoid arthritis
- Systemic sclerosis (including more localized CREST)
- Systemic lupus erythematosus
- Mixed connective tissue disease
- Thromboangiitis
- Thoracic outlet compression syndrome
- Carpal tunnel syndrome
- Acrocyanosis
- Cryoglobulinemia
- Reflex sympathetic dystrophy
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Diagnosis |
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Physical Examination |
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White-blue-red sequence of changes in digits after exposure to cold or
emotional disturbance; secondary form may present pitting scars and ulcers of
the skin or gangrene in fingers or toes. |
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Laboratory Tests |
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A variety of laboratory tests may reveal abnormalities, but they are not
considered diagnostic alone. These include:
- Nail fold capillaroscopy, to distinguish between primary and
secondary forms
- Antinuclear antibody test (ANA), to assess for antibodies due to
connective tissue disease or other autoimmune disorder
- Erythrocyte sedimentation rate (ESR), to measure
inflammation
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Pathology/Pathophysiology |
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Appears to result from an exaggeration of normal physiological responses
involving vasculature constriction. May include episodic digital ischemia
secondary to exaggerated reflex sympathetic vasoconstriction; enhanced digital
vascular responsiveness to cold or normal sympathetic stimuli; normal reflex
sympathetic vasoconstriction superimposed on local digital vascular disease;
enhanced adrenergic neuroeffector activity. |
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Other Diagnostic
Procedures |
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- Clinician interview—assess symptoms and
degree of severity; detailed medical history and patient report essential since
attacks are intermittent; if psychological in origin, patient may have an attack
due to stress when being examined
- Evaluate for medical conditions, stress, possible pharmacological
side effects
- The Allen test (radial/ulnar arteries) may help distinguish between
occlusion vs. vasospasm. The Taylor-Pelmear scale system is used to classify
vibration-induced disease. Provocative exposure to
cold.
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Treatment Options |
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Treatment Strategy |
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The primary goal is to reduce frequency and severity of episodes, prevent
tissue damage, and treat underlying disease if present. Conservative nondrug and
self-help measures (e.g., dressing warmly and avoiding the cold, smoking
cessation) are used for mild and infrequent episodes. For severe cases, options
include:
- Pharmacotherapy
- Sympathectomy (if symptoms are progressive)
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Drug Therapies |
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- Calcium-channel blockers (vasodilators) such as nifedipine
(sustained-release, 10 to 30 mg tid) and diltiazem (30 to 90 mg tid) may benefit
severe cases, especially with presence of peripheral vasoconstriction without
significant organic vascular disease; side effects include headache, dizziness,
flushing, palpitations, dyspepsia, pruritus, and edema.
- Adrenergic blocking agents such as resperine (0.25 to 0.5 mg tid) may
increase nutritional blood flow to digits; side effects include hypotension,
nasal stuffiness, lethargy, and depression.
- Postsynaptic alpha-adrenergic antagonist such as prazosin (1 to 5 mg
tid)
- Doxazosin and terazosin
- Sympatholytic agents, including methyldopa, guanethidine, and
phenoxybenzamine
- Prostaglandins to inhibit platelet aggregation; side effects include
voiding and/or diarrhea and hypertension
- Angiotensin-converting enzyme inhibitors such as captopril reduce
peripheral resistance, sympathetic nervous system activity, and norepinephrine
release due to angiotensin suppression.
- Serotonin S2 antagonist (Ketanserin) antagonizes serotonin S2 and
blocks adrenergic receptors to inhibit vasoconstriction and platelet aggregation
stimulated by serotonin; not available in the United States.
- Nitroglycerine relaxes smooth muscle, dilates veins, lowers oxygen
need in the myocardial tissues, inhibits platelet aggregation.
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Complementary and Alternative
Therapies |
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Raynaud's is a poorly understood syndrome that may be helped with alternative
therapies that improve circulation and support general health. Begin with
nutritional support and circulatory stimulants.
Biofeedback may allow patient to bring digit temperature under voluntary
control. Autogenic training has been found to be an effective technique for
Raynaud's phenomenon. |
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Nutrition |
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- Vitamin E (400 to 800 IU/day) improves circulation and inhibits
platelet aggregation.
- Vitamin C (1,000 mg bid to tid) supports connective tissue and
reduces inflammation.
- B-complex (50 to 100 mg/day) reduces the effects of
stress.
- Coenzyme Q10 (100 mg bid) enhances tissue oxygenation.
- Calcium (1,500 mg/day) and magnesium (200 mg tid) relieve
spasm.
- Omega-3 oils (1,500 mg bid to tid) are anti-inflammatory and inhibit
platelet aggregation.
- Zinc (30 to 50 mg/day) is required for normal immune
function.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas
should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 20
minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in
combination as noted.
The following herbs are circulatory stimulants with other properties as well.
Use one or more tinctures in combination, 20 to 30 drops bid.
- Hawthorn berries (Crataegus
laevigata)—enhance vascular integrity, and has mild
vasodilatory effects
- Ginkgo (Ginkgo biloba)—120 to 160
mg/day for dried extracts, inhibits platelet aggregation
- Rosemary (Rosmarinus officinalis)—is
a gentle relaxant
- Ginger root (Zingiber officinale)—is
a mild anodyne
- Prickly ash bark (Xanthoxylum
clava-herculis)—enhances lymph activity and
vascular integrity
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency.
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Acupuncture |
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Acupuncture may be useful as an adjunctive therapy to increase circulation
and reduce vasospasm. |
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Massage |
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Therapeutic massage or bath using essential oils may help ease symptoms. A
basic formula includes six drops of a blend of nutmeg (Myristica
fragrans, 15 drops), lavender (Lavandula angustifolia, 5 drops), and
geranium (Pelagronium graveolens, 10 drops) for bath; add 2 tbsp.
vegetable oil for massage; other essential oils used in massage include cypress
(Cupressus sempervirens), neroli (Citrus aurantium), lemon
(Citrus limon), or rose (Rosa gallica) in 2 tsp. base oil.
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Patient Monitoring |
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All patients should avoid or quit smoking since nicotine is a
vasoconstrictor. |
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Other
Considerations |
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Prevention |
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Patient should protect himself or herself from exposure to cold and guard
against cuts and other injury to affected areas. Exercise, such as raising arms
above head and whirling them vigorously, may help circulation. Biofeedback may
help patient prevent or stop attacks. |
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Complications/Sequelae |
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Dry gangrene is a serious but rare complication. Other complications include
ulceration of affected parts and deformities of fingers/fingernails or
toes/toenails. |
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Prognosis |
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Progressive course, yet management techniques are successful in 40% to 60% of
symptoms of Raynaud's phenomenon patients. Mild cases of vibration-induced
disease should recover if causal activity is avoided. |
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Pregnancy |
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Some medications used to treat Raynaud's phenomenon may affect the growing
fetus. |
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References |
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Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed.
Garden City Park, NY: Avery Publishing Group; 1997.
Batchelder HJ. Allopathic specific condition review: Raynaud's disease.
Protocol J Botan Med. 1996;2:134-137.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Mitchell W, Batchelder HJ. Naturopathic specific condition review: Raynaud's
disease. Protocol J Botan Med. 1996;2:138-140.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis
& Treatment 1999. 38th ed. Stamford, Conn: Appleton & Lange;
1999. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. |