Treatment of Raynaud's phenomenon

Toxin for Treating Raynaud Conditions in Hands (The TORCH Study): A Systematic Review and Meta-analysis

Background

Raynaud disease of the hands is a complex disorder resulting in inappropriate constriction and/or insufficient dilation in microcirculation. There is an emerging role for botulinum toxin type A (BTX-A) in the treatment armamentarium for refractory Raynaud disease. The aim of this systematic review was to critically evaluate the management of primary and secondary Raynaud disease treated with BTX-A intervention.

Methods

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of clinical studies assessing treatment of primary or secondary Raynaud disease with BTX-A by searching Ovid MEDLINE and Embase databases from inception to first August 2023. The review protocol was prospectively registered on the PROSPERO database (CRD42022312253).

Results

Our search strategy identified 288 research articles, of which 18 studies [four randomized controlled trials (RCTs), two non-RCTs, five case series, and seven retrospective cohort studies] were eligible for analysis. Meta-analysis demonstrated that the probability of pain visual analog scale score improvement with BTX-A intervention was 81.95% [95% confidence interval (74.12-87.81) P = 0.19, heterogeneity I 2 = 26%] and probability of digital ulcer healing was 79.37% [95% confidence interval (62.45-89.9) P = 0.02, heterogeneity I 2 = 56%].

Conclusions

Delivery of BTX-A to digital vessels in the hand may be an effective management strategy for primary and secondary Raynaud disease. A definitive, appropriately-powered RCT with objective functional and patient-reported outcome measures is required to accurately assess and quantify the efficacy of BTX-A in Raynaud disease of the hands.

Phosphodiesterase 5 inhibitors (PDE5i) for the treatment of Raynaud's phenomenon

BACKGROUND

Raynaud's phenomenon is a vasodilatory phenomenon characterised by digital pallor, cyanosis, and pain of the extremities. Primary Raynaud's phenomenon has no underlying disease associated with it, while secondary Raynaud's phenomenon is associated with connective tissue disorders such as systemic sclerosis. Systemic sclerosis causes fibrosis and commonly affects the skin and internal organs such as the gastrointestinal tract, lungs, kidney, and heart. Phosphodiesterase 5 inhibitors (PDE5i) are a class of drugs that increases blood flow to the extremities and may be beneficial in the treatment of Raynaud's phenomenon.

OBJECTIVES

To assess the benefits and harms of PDE5i compared to placebo for the treatment of Raynaud's phenomenon.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries up to June 2022. We did not apply any language restrictions. We searched the bibliographies of retrieved articles and contacted key experts in the field for additional and unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PDE5i to placebo in people with primary and secondary Raynaud's phenomenon.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review included nine RCTs which ranged in duration from four to eight weeks and included a total of 411 participants. The majority had Raynaud's phenomenon secondary to systemic sclerosis. Tadalafil was assessed in four studies, sildenafil in three studies, vardenafil in one study, and a new PDE5 inhibitor known as "PF-00489791" in one study. Three studies were parallel design and six studies were cross-over. The frequency of attacks per week was 24 with placebo and PDE5i reduced the frequency of attacks by an average of three attacks per week (mean difference (MD) -3.07, 95% confidence interval (CI) -5.15 to -1.00; 8 studies; low-certainty evidence). The duration of attacks per day was 55 minutes with placebo and PDE5i reduced the duration of attacks by an average of five minutes (MD -5.31, 95% CI -8.90 to -1.71; 8 studies; low-certainty evidence). Very low-certainty evidence from one study with eight participants showed severity of Raynaud's attacks (assessed on a 10 cm visual analogue scale with lower scores indicating less severity) was 20% lower with a PDE5i (3.7 with placebo compared to 1.6 with treatment; MD -2.1, 95% CI -2.7 to 1.4; very low-certainty evidence). Pain and patient global assessment were assessed on a 10 cm visual analogue scale with lower scores indicating improvement. Low-certainty evidence showed that the use of PDE5i may result in little to no difference compared to placebo in reducing the average pain of Raynaud's attacks (3 to 2.9; MD -0.10, 95% CI -0.78 to 0.57; 4 studies). Global scores were 36% lower with the use of a PDE5i compared to placebo (9.2 to 5.6; MD -3.59, 95% CI -4.45 to -2.73; 1 study, 24 participants; low-certainty evidence). The rate of withdrawals during treatment with PDE5i ranged from 4% to 20% compared with 2% in the placebo group in five studies. Four studies reported no withdrawals due to adverse events. Seven studies reported no serious adverse events. The rate of serious adverse events reported in two studies ranged from 2% during treatment to 4% with placebo. The majority of the studies were judged as low or unclear risk of bias for selection, performance, and detection bias. Almost half were judged at high risk of attrition bias and unclear risk for selective reporting bias. We downgraded frequency of attacks, duration of attacks, pain intensity, and patient global assessment for small sample sizes and concerns about inconsistency and graded each as low certainty of evidence. We downgraded severity of attacks to very low certainty due to serious concerns about imprecision and publication bias. We downgraded withdrawals due to adverse events and serious adverse events to moderate certainty of evidence due to a low number of reported events.

AUTHORS' CONCLUSIONS

Based on low-certainty evidence, PDE5i may reduce the frequency of attacks of Raynaud's phenomenon by a small amount per week, result in a small reduction in the duration of attack, improve patients' global assessment of their disease, and result in little to no difference in pain. PDE5i probably result in little or no difference in serious adverse events but slightly increase the likelihood of withdrawing from treatment due to an adverse event.

Алгоритмы лечения системной склеродермии при преимущественном поражении кожи и суставов, при синдроме Рейно и дигитальных язвах согласно современным рекомендациям

Системная склеродермия (ССД) (системный склероз) является уникальным заболеванием среди ревматических болезней, поскольку представляет проблему менеджмента хронической мультисистемной аутоиммунной патологии с широко распространенной облитерирующей васкулопатией малых артерий, связанной с разной степенью фиброза тканей. В патологический процесс могут вовлекаться все органы, так или иначе связанные с соединительной тканью и имеющие кровеносные сосуды. Прогрессирующее течение ССД приводит к развитию необратимых фиброзных изменений, в результате которых происходит нарушение функции пораженных органов. Отличительной чертой ССД является клиническая неоднородность подгрупп больных, которые различаются в зависимости от степени тяжести заболевания, вовлечения тех или иных органов и систем и дальнейшего прогноза. Врач должен тщательно обследовать каждого пациента с ССД для определения конкретных проявлений и уровня активности заболевания для назначения соответствующего лечения. В настоящее время использование алгоритмов лечения является современной стратегией ведения пациентов, особенно после неудачного использования препаратов первой линии. При ранней активной диффузной склеродермии с преимущественным поражением кожи следует отдать предпочтение метотрексату (МТХ) в качестве препарата первой линии, а при его неэффективности или непереносимости препаратом второй линии является мофетила микофенолат (ММФ), при неэффективности последнего препаратом третьей линии является внутривенный циклофосфамид. Следует заметить, что при тяжелом поражении кожи препаратом первой линии является ММФ, а МТХ — вторым, при неэффективности ММФ. На сегодняшний день блокаторы кальциевых каналов (БКК), главным образом нифедипин, остаются препаратами первой линии для терапии синдрома Рейно при ССД. При неэффективности этих лекарственных средств следует добавить ингибиторы фосфодиэстеразы-5 (иФДЕ-5), следующим шагом терапии является назначение ингибиторов ангиотензинпревращающего фермента или блокаторов рецепторов ангиотензина. При неэффективности комбинированной терапии БКК и иФДЕ-5, при тяжелом течении синдрома Рейно следует использовать простаноиды. Препаратом первой линии для лечения артрита, как и для поражения кожи, является МТХ, при его неэффективности или высокой воспалительной активности следует добавить глюкокортикоиды и нестероидные противовоспалительные препараты. Гидроксихинолон является препаратом третьей линии, его добавляют к терапии при неэффективности вышеперечисленных агентов. Биологические агенты (ритуксимаб и тоцилизумаб) являются препаратами четвертой линии лечения артрита, ассоциированного с ССД.

EXTRA-ARTICULAR MANIFESTATIONS OF RHEUMATOID ARTHRITIS

Rheumatoid arthritis (RA) is an immune inflammatory (autoimmune) rheumatic disease of unknown etiology, which is characterized by chronic erosive arthritis and systemic damage to the viscera, and leads to early disability and reduced survival in patients. For its diagnosis, it is currently recommended to use the 2010 ACR/EULAR classification criteria for RA, which should be applied in clinical trials to identify at least one swollen joint, i.e. the presence of arthritis; therefore, the problem of extra-articular manifestations of RA is apparent to stay in the background.

Calcium channel blockers for primary and secondary Raynaud's phenomenon

BACKGROUND

Raynaud's phenomenon is a vasospastic disease characterized by digital pallor, cyanosis, and extremity pain. Primary Raynaud's phenomenon is not associated with underlying disease, but secondary Raynaud's phenomenon is associated with connective tissue disorders such as systemic sclerosis, systemic lupus erythematosus, and mixed connective tissue disease. Calcium channel blockers promote vasodilation and are commonly used when drug treatment for Raynaud's phenomenon is required.

OBJECTIVES

To assess the benefits and harms of calcium channel blockers (CCBs) versus placebo for treatment of individuals with Raynaud's phenomenon with respect to Raynaud's type (primary vs secondary) and type and dose of CCBs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (May 19, 2017), MEDLINE (1946 to May 19, 2017), Embase (1947 to May 19, 2017), clinicaltrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Portal. We applied no language restrictions. We also searched bibliographies of retrieved articles and contacted key experts for additional and unpublished data.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing calcium channel blockers versus placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed search results and risk of bias and extracted trial data. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

This review contains 38 RCTs (33 cross-over RCTs) with an average duration of 7.4 weeks and 982 participants; however, not all trials reported all outcomes of interest. Nine of the identified trials studied patients with primary Raynaud's phenomenon (N = 365), five studied patients with secondary Raynaud's phenomenon (N = 63), and the rest examined a mixture of patients with primary and secondary Raynaud's phenomenon (N = 554). The most frequently encountered risk of bias types were incomplete outcome data and poor reporting of randomization and allocation methods.When researchers considered both primary and secondary Raynaud's phenomenon, evidence of moderate quality (downgraded for inconsistency) from 23 trials with 528 participants indicates that calcium channel blockers (CCBs) were superior to placebo in reducing the frequency of attacks. CCBs reduced the average number of attacks per week by six ( weighted mean difference (WMD) -6.13, 95% confidence interval (CI) -6.60 to - 5.67; I² = 98%) compared with 13.7 attacks per week with placebo. When review authors excluded Kahan 1985C, a trial showing a very large reduction in the frequency of attacks, data showed that CCBs reduced attack frequency by 2.93 per week (95% CI -3.44 to -2.43; I² = 77%).Low-quality evidence (downgraded for imprecision and inconsistency) from six trials with 69 participants suggests that the average duration of attacks did not differ in a statistically significant or clinically meaningful way between CCBs and placebo (WMD -1.67 minutes, 95% CI -3.29 to 0); this is equivalent to a -9% difference (95% CI -18% to 0%).Moderate-quality evidence (downgraded for inconsistency) based on 16 trials and 415 participants showed that CCBs reduced attack severity by 0.62 cm (95% CI -0.72 to - 0.51) on a 10-cm visual analogue scale (lower scores indicate less severity); this was equivalent to absolute and relative percent reductions of 6% (95% CI -11% to -8%) and 9% (95% CI -11% to -8%), respectively, which may not be clinically meaningful.Improvement in Raynaud's pain (low-quality evidence; downgraded for imprecision and inconsistency) and in disability as measured by a patient global assessment (moderate-quality evidence; downgraded for imprecision) favored CCBs (pain: WMD -1.47 cm, 95% CI -2.21 to -0.74; patient global: WMD -0.37 cm, 95% CI -0.73 to 0, when assessed on a 0 to 10 cm visual analogue scale, with lower scores indicating less pain and less disability). However, these effect estimates were likely underpowered, as they were based on limited numbers of participants, respectively, 62 and 92. For pain assessment, absolute and relative percent improvements were 15% (95% -22% to -7%) and 47% (95% CI -71% to -24%), respectively. For patient global assessment, absolute and relative percent improvements were 4% (95% CI -7% to 0%) and 9% (95% CI -19% to 0%), respectively.Subgroup analyses by Raynaud's type, CCB class, and CCB dose suggest that dihydropyridine CCBs in higher doses may be more effective for primary Raynaud's than for secondary Raynaud's, and CCBs likely have a greater effect in primary than in secondary Raynaud's. However, differences were small and were not found for all outcomes. Dihydropyridine CCBs were studied as they are the subgroup of CCBs that are not cardioselective and are traditionally used in RP treatment whereas other CCBs such as verapamil are not routinely used and diltiazem is not used as first line subtype of CCBs. Most trial data pertained to nifedipine.Withdrawals from studies due to adverse effects were inconclusive owing to a wide CI (risk ratio [RR] 1.30, 95% CI 0.51 to 3.33) from two parallel studies with 63 participants (low-quality evidence downgraded owing to imprecision and a high attrition rate); absolute and relative percent differences in withdrawals were 6% (95% CI -14% to 26%) and 30% (95% CI -49% to 233%), respectively. In cross-over trials, although a meta-analysis was not performed, withdrawals were more common with CCBs than with placebo. The most common side effects were headache, dizziness, nausea, palpitations, and ankle edema. However, in all trials, no serious adverse events (death or hospitalization) were reported.

AUTHORS' CONCLUSIONS

Randomized controlled trials with evidence of low to moderate quality showed that CCBs (especially the dihydropyridine class) may be useful in reducing the frequency, duration, severity of attacks, pain and disability associated with Raynaud's phenomenon. Higher doses may be more effective than lower doses and these CCBs may be more effective in primary RP. Although there were more withdrawals due to adverse events in the treatment groups, no serious adverse events were reported.

The role of botulinum toxin in vasospastic disorders of the hand

Raynaud phenomenon may be a primary disorder or associated with a variety of other autoimmune processes. Raynaud phenomenon produces digital vasospasm, which can lead to ischemia and ulceration. The treatment of Raynaud phenomenon has been difficult because multiple medical treatments have not provided uniform resolution of symptoms. Many patients have turned to surgery and sympathectomies for the treatment of unrelenting vasospasm. Botulinum toxin has been shown to be an effective alternative to surgery, with a single treatment being capable of resolving pain and healing ulcer. This article reviews the use of botulinum toxin for the treatment of Raynaud phenomenon.

Raynaud's phenomenon: from molecular pathogenesis to therapy

Raynaud's phenomenon (RP) is a well defined clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical/chemical or emotional stress. RP has been classified as primary or secondary, depending on whether it occurs as an isolated condition (pRP) or is associated to an underlying disease, mainly a connective tissue disease (CTD-RP). In both cases, it manifests with unique "triple" (pallor, cyanosis and erythema), or "double" color changes. pRP is usually a benign condition, while sRP can evolve and be complicated by acral digital ulcers and gangrene, which may require surgical treatment. The pathogenesis of RP has not yet been entirely clarified, nor is it known whether autoantibodies have a role in RP. Even so, recent advances in our understanding of the pathophysiology have highlighted novel potential therapeutic targets. The aim of this review is to discuss the etiology, epidemiology, risk factors, clinical manifestations, recently disclosed pathogenic mechanisms underlying RP and their correlation with the available therapeutic options, focusing primarily on pRP and CTD-RP.

Antihypertensive Drugs in Patients Treated with Antiretroviral

Objective:

To review the literature for information regarding pharmacokinetic interactions between antiretrovirals and antihypertensive agents, evaluate the clinical significance of these interactions, and analyze the effect of antihypertensive drugs on the metabolic complications frequently observed in HIV-infected patients to emphasize the advantages and inconveniences of every class of antihypertensive drugs in association with antiretrovirals.

Data Sources:

A literature search was conducted via PubMed and MEDLINE (1950-November 2011) using the search terms drug interactions, cytochrome P450, names of antiretrovirals, names of commonly prescribed antihypertensive drugs, pharmacokinetics, and metabolic complications. Reference citations from relevant publications, manufacturers’ product information, and www.HIV-druginteracttons.org were also reviewed.

Study Selection And Data Extractions:

All articles with an English abstract identified through the data search were examined. Of these, pharmacologic reviews, studies, and case reports were evaluated.

Data Synthesis:

Antihypertensive drugs interact with several antiretroviral drugs, non nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (Pls) in particular. Pharmacokinetic interactions are less expected with diuretics, jî-blockers excreted by the kidney, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) other than losartan and irbesartan. Calcium channel blockers (CCBs) are metabolized by CYP3A4, with the potential for interaction with NNRTIs and Pls. Because CCBs do not adversely affect glucose or lipid metabolism or renal function, they may be preferred in patients with such complications. ACE inhibitors and ARBs may exert favorable effects on glucose homeostasis. In addition, they may significantly reduce protein excretion and further slow the progression of renal disease.

Conclusions:

The choice of antihypertensive drugs in HIV-infected patients is complex and must take into account the metabolic pathways of antiretroviral drugs and antihypertensive drugs with the potential of pharmacokinetic interactions, as well as the effect of antihypertensive drugs on some biological parameters.

Raynaud’s syndrome, 2011

Raynaud’s phenomenon is characterized by intense vasospasm of the digital arteries on cold exposure or emotional stress, leading to well-defined colour changes in the skin of the fingers. Behind the clinical manifestations, there is an imbalance between vasoconstrictor and vasodilator factors. It may be primary or secondary to an underlying condition, including autoimmune diseases. Physical examination, nail fold capillaroscopy and immunological tests can differentiate primary forms from secondary ones. The treatment is based on preventing exposure to cold, emotional stress and the administration of certain drugs and, if attacks are present, vasodilators, prostaglandin analogues and anticoagulants may be given. This review focuses on the characteristics of Raynaud’s phenomenon and the available diagnostic and therapeutic options. Orv. Hetil., 2012, 153, 403–409.

Extra-articular manifestations of rheumatoid arthritis: An update

Rheumatoid arthritis (RA) is an immune-mediated disease involving chronic low-grade inflammation that may progressively lead to joint destruction, deformity, disability and even death. Despite its predominant osteoarticular and periarticular manifestations, RA is a systemic disease often associated with cutaneous and organ-specific extra-articular manifestations (EAM). Despite the fact that EAM have been studied in numerous RA cohorts, there is no uniformity in their definition or classification. This paper reviews current knowledge about EAM in terms of frequency, clinical aspects and current therapeutic approaches. In an initial attempt at a classification, we separated EAM from RA co-morbidities and from general, constitutional manifestations of systemic inflammation. Moreover, we distinguished EAM into cutaneous and visceral forms, both severe and not severe. In aggregated data from 12 large RA cohorts, patients with EAM, especially the severe forms, were found to have greater co-morbidity and mortality than patients without EAM. Understanding the complexity of EAM and their management remains a challenge for clinicians, especially since the effectiveness of drug therapy on EAM has not been systematically evaluated in randomized clinical trials.

Paracrine control of vascular innervation in health and disease

Proper vascular regulation is of paramount importance for the control of blood flow to tissues. In particular, the regulation of peripheral resistance arteries is essential for several physiological processes, including control of blood pressure, thermoregulation and increase of blood flow to central nervous system and heart under stress conditions such as hypoxia. Arterial tone is regulated by the periarterial autonomic nervous plexus, as well as by endothelium-dependent, myogenic and humoral mechanisms. Underscoring the importance of proper vascular regulation, defects in these processes can lead to diseases such as hypertension, orthostatic hypotension, Raynaud's phenomenon, defective thermoregulation, hand-foot syndrome, migraine and congestive heart failure. Here, we review the molecular mechanisms controlling the development of the periarterial nerve plexus, retrograde and localized signalling at neuro-effector junctions, the molecular and cellular mechanisms of vascular regulation and adult plasticity and maintenance of periarterial innervation. We particularly highlight a newly discovered role for vascular endothelial growth factor in the structural and functional maintenance of arterial neuro-effector junctions. Finally, we discuss how defects in neuronal vascular regulation can lead to disease.

Systemic sclerosis refractory disease: from the skin to the heart

Systemic sclerosis or scleroderma (SSc) is an heterogeneous disease involving the connective tissue and the microvasculature with fibrosis and vascular occlusion. It is difficult to define refractory SSc once it is itself a paradigm of a refractory condition: there is no evidence of when to act to stop the progression to fibrosis and irreversible microvascular damage. There is no definition of refractory disease in SSc and to propose a definition we used mainly the Medsger severity index and the EULAR 2009 treatment recommendations from the skin to the heart through peripheral vascular, musculoskeletal, gastrointestinal, renal, pulmonary hypertension and interstitial lung disease. We used some clinical setting reflecting the different reasoning when there is probable refractory disease and finally we briefly pointed out some available treatment options to refractory disease. With this reflection, we would like to open paths to a broader discussion.

The effect of metoprolol alone and combined metoprolol-felodipin on the digital microcirculation of patients with primary Raynaud's syndrome

OBJECTIVES

Calcium channel inhibitors have beneficial impact on microcirculation, but beta-blocker effect is controversial. Clinicians still do not agree on beta-blocker combination with other treatments in the management of impaired microcirculation. The aim of the present study was to describe the effects of beta-blocker metoprolol monotherapy and combined with calcium channel inhibitor felodipin on digital microcirculation in primary Raynaud's syndrome.

METHODS

We enrolled in this study 46 patients suffering from both hypertension and primary Raynaud's syndrome. Fifteen patients were treated with beta-blocker monotherapy (metoprolol), 13 received combined beta-blocker and calcium channel blocker therapy (felodipin and metoprolol), while 18 patients without any medications served as controls. Measurement of digital microcirculation was carried out with laser Doppler scanner.

RESULTS AND CONCLUSIONS

Our investigation concludes that the concurrent administration of beta-blockers with calcium channel inhibitors positively reduces symptoms in patients suffering from Raynaud's syndrome.

Perianesthesia management of Raynaud's phenomenon--a case report

This article presents a case report of a 52-year-old female patient with lung cancer presenting with Raynaud's phenomenon during thoracic surgery. Experiences and lessons learned from this case are presented. The classification, pathogenesis, and perianesthesia management of Raynaud's phenomenon are discussed.

Recent achievements in the management of Raynaud's phenomenon

Raynaud's phenomenon is a clinical disorder with episodic digital ischemic vasospasm triggered by cold- or emotional-stress. It was first mentioned by Maurice Raynaud in 1862 describing "a local asphyxia of the extremities" and was further divided into primary Raynaud's disease and secondary Raynaud's phenomenon, which is often related to connective tissue diseases, but also physical or chemical strain. Though pathophysiology of Raynaud's phenomenon is still poorly understood, systemic and local vascular effects are most likely to be involved in primary Raynaud's disease. In secondary Raynaud's phenomenon additional abnormalities in vascular structure and function may play the major role. Thus, medical treatment of Raynaud's phenomenon remains unsatisfactory, due to limited understanding of pathophysiological mechanisms. This review addresses current evidence for medical treatment of primary and secondary Raynaud's phenomenon with regard to pathophysiological mechanisms as well as future perspectives.

Homocysteine and Raynaud's phenomenon: a review

Raynaud's phenomenon, categorized as primary and secondary when occurring isolated or in association with an underlying disease, respectively, is a paroxysmal and recurrent acral ischemia resulting from an abnormal arterial vasospastic response to cold or emotional stress. The key issue in the pathogenesis of Raynaud's phenomenon is presumed to be a dysregulation in the mechanisms of vascular motility resulting in an imbalance between vasodilatation and vasoconstriction. Homocysteine, a non-protein forming sulphured amino acid proposed as an independent risk factor for atherothrombosis in the general population, clearly demonstrated to produce vascular damage through mechanisms also including endothelial injury and modifications in circulating mediators of vasomotion. The rationale for homocysteine involvement in the pathogenesis of Raynaud's phenomenon led some authors to investigate the possible association between mild hyperhomocysteinemia and such a vascular disturbance, particularly in the course of connective tissue disease. Here we review data regarding this putative association and the supposed mechanisms involved, also discussing the emblematic case of a patient with new-onset severe Raynaud's phenomenon and markedly elevated homocysteinemia.