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Raynaud’s phenomenon

Raynaud’s phenomenon. When is it serious? Neil McHugh Bath Clinic June 2011. Raynaud’s phenomenon. Maurice Raynaud (1834 – 1881) De l'asphyxie locale et de la gangrène symétrique des extrémités. Doctoral thesis, published February 25, 1862. Primarily affects fingers

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Raynaud’s phenomenon

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  1. Raynaud’s phenomenon When is it serious? Neil McHugh Bath Clinic June 2011

  2. Raynaud’s phenomenon Maurice Raynaud (1834 – 1881) De l'asphyxie locale et de la gangrène symétrique des extrémités. Doctoral thesis, published February 25, 1862.

  3. Primarily affects fingers Can affect toes, thumbs, nipples, nose, earlobes Episodes precipitated by cold exposure and emotional stress Episodes accompanied by pain +/- numbness Pulses present Necrosis / tissue damage suggestive of secondary cause Clinical features or Raynaud’s Initial ischaemia Pallor Cyanotic phase Blue Hyperaemic phase Red / purple

  4. Definition of RP • Definite repetitive episodes of biphasic colour change (at least 2 of pallor, cyanosis, erythema), in either cold or normal environment

  5. Pathogenesis

  6. Causes • Primary (~10-15% of healthy population, female predominance) • Secondary • Drugs e.g. Beta blockers • Connective tissue disorders e.g. systemic sclerosis • Eating disorders • Haematological e.g. cold agglutinins • Vascular occlusion e.g. vasculitis, thoracic outlet obstruction, Buerger’s disease • Occupation e.g. vibrating tool use • Others e.g. hypothyroidism, carpal tunnel syndrome

  7. Is it seconday Raynaud’s? • History • Severity, age of onset, gender, symptoms of CTD etc • Clinical examination • Radial pulses • Skin changes • Nailfold changes • Joint disease • Carpal Tunnel Syndrome • Laboratory investigations • FBC, U&E, LFT, CRP, TSH • Autoimmune profile • Nailfold capillaroscopy • Infrared thermography

  8. Systemic sclerosis

  9. Laser Speckle Contrast Imaging Systemic sclerosis Healthy control

  10. Management • General measures • Raynaud’s and Scleroderma Association • www.raynauds.org.uk • Scleroderma Society • Sclerodermasociety.co.uk • Arthritis Research UK (formerly ARC) • www.arthritisresearchuk.org • Maintenance of core temperature • Avoidance of cold exposure • Cessation of vasoconstrictive Rx e.g. B blockers • Gloves (heated) • Smoking cessation

  11. Promoting vasodilation • Calcium channel blockers • Dihydropyridine • Nifedipine better than amlodipine • Nitrates • Transdermal or oral • Prostaglandins • IV (disappointing results with oral preparation) • Phosphodiesterase V inhibitors • Under investigation. Remain expensive.

  12. Preventing vasoconstriction • ACEi and ARBs • e.g. losartan • May be better in primary RP • Alpha adrenoceptor blockade • e.g. prazosin • SSRIs • e.g. fluoxetine • May be better in primary Raynaud’s • Endothelin receptor antagonists • e.g. bosentan • Reserved for use in CTD

  13. Novel treatments • Rho kinase inhibitors • Responsible for cold-induced expression of alpha-2 adrenoceptors • Statins • In part due to Rho kinase inhibition • Antiplatelet treatments? • Current trial at RNHRD (for primary and secondary Raynaud’s)

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