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Ture HY, Lee NY, Kim NR, Nam EJ. Raynaud's Phenomenon: A Current Update on Pathogenesis, Diagnostic Workup, and Treatment. Vasc Specialist Int 2024; 40:26. [PMID: 39040029 PMCID: PMC11266082 DOI: 10.5758/vsi.240047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/24/2024] Open
Abstract
Raynaud's phenomenon (RP) is a condition characterized by episodic, excessive vasoconstriction in the fingers and toes, triggered by cold or stress. This leads to a distinctive sequence of color changes in the digits. Pallor indicates reduced blood flow due to oxygen deprivation, while erythema appears as reperfusion. RP can be primary, with no identifiable underlying cause, or secondary, associated with other conditions. These conditions include autoimmune diseases, most commonly systemic sclerosis, vascular diseases; and neurological conditions. While the exact cause of RP remains unclear, genetic and hormonal (estrogen) factors are likely contributors. The pathogenesis of RP involves a complex interaction between the vascular wall, nerves, hormones, and humoral factors, disrupting the balance between vasoconstriction and vasodilation. In primary RP, the vascular abnormalities are primarily functional. However, in secondary RP, both functional and structural components occur in blood vessels. This explains why digital tissue damage frequently occurs in secondary RP but not primary RP. Diagnosis of RP is primarily clinical. Recent advancements in imaging techniques have aided in diagnosis and monitoring, but nail fold capillaroscopy remains the gold standard for distinguishing between primary and secondary RP. If there are signs of acute ischemic injury, vascular imaging, particularly preoperatively, is crucial to rule out other vaso-occlusive conditions. Management of RP focuses on alleviating symptoms and preventing tissue damage. Vasodilator medications are the first-line treatment when general measures like warmth and stress management are not sufficient. Dihydropyridine calcium channel blockers (CCBs), such as nifedipine, are commonly used for vasodilation. Phosphodiesterase-5 inhibitors and prostaglandin analogs are alternative options for patients who do not respond to CCBs or have ischemic tissue damage. Bosentan, an endothelin-1 receptor antagonist, has shown effectiveness in treating and preventing digital ulcers, especially in patients with multiple ulcers. For severe cases, botulinum toxin injections or sympathectomy surgery can be used to control RP symptoms. However, botulinum toxin injections require repeated administration, and sympathectomy's long-term effectiveness is uncertain. Fat grafting is a promising surgical therapy for promoting healing and preventing tissue injury.
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Affiliation(s)
- Hirut Yadeta Ture
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Nan Young Lee
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Na Ri Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eon Jeong Nam
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Amaral MC, Paula FS, Caetano J, Ames PR, Alves JD. Re-evaluation of nailfold capillaroscopy in discriminating primary from secondary Raynaud's phenomenon and in predicting systemic sclerosis: a randomised observational prospective cohort study. Expert Rev Clin Immunol 2024; 20:665-672. [PMID: 38465507 DOI: 10.1080/1744666x.2024.2313642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/23/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Primary Raynaud's phenomenon (pRP) is difficult to distinguish from secondary (sRP). Although nailfold capillaroscopy (NFC) may detect early alterations, no universal criteria yet discriminate between pRP from sRP. OBJECTIVES To create and validate two NFC scores that could distinguish pRP from sRP and that could predict systemic sclerosis (SSc), respectively. METHODS We performed NFC on two separate cohorts with isolated RP, and recorded number of capillaries per field, enlarged/giant capillaries, crossed/bizarre patterns, microhemorrhages, neoangiogenesis, rarefaction, edema, blood flow velocity, stasis. By multivariate regression analysis, we evaluated the adjusted prognostic role of these features in a derivation cohort of 656 patients. Results were used to construct algorithm-based prognostic scores (A and B). These scores were then tested on a confirmation cohort of 219 patients. RESULTS Score A was unable to discriminate sRP from pRP (low negative predictive values with high positive predictive values for any cut-point); score B was unable to discriminate progression to SSc or a SSc-spectrum disorder (low positive predictive values with high negative predictive values for lower cut-points). CONCLUSION NFC patterns, believed as specific, showed low discriminatory power and on their own are unable to reliably discriminate sRP from pRP or predict evolution to SSc.
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Affiliation(s)
- Marta C Amaral
- Immune response and vascular disease, iNOVA4Health, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- UDIMS - Unidade de Doenças Imuno-Mediadas Sistémicas, Departamento de Medicina IV, Hospital Prof. Doutor Fernando Fonseca, E.P.E, Amadora, Portugal
| | - F Seguro Paula
- Immune response and vascular disease, iNOVA4Health, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- UDIMS - Unidade de Doenças Imuno-Mediadas Sistémicas, Departamento de Medicina IV, Hospital Prof. Doutor Fernando Fonseca, E.P.E, Amadora, Portugal
| | - Joana Caetano
- Immune response and vascular disease, iNOVA4Health, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- UDIMS - Unidade de Doenças Imuno-Mediadas Sistémicas, Departamento de Medicina IV, Hospital Prof. Doutor Fernando Fonseca, E.P.E, Amadora, Portugal
| | - Paul Rj Ames
- Immune response and vascular disease, iNOVA4Health, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- Department of Haematology, Dumfries & Galloway Royal Infirmary, Cargenbridge, Scotland, UK
| | - J Delgado Alves
- Immune response and vascular disease, iNOVA4Health, NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- UDIMS - Unidade de Doenças Imuno-Mediadas Sistémicas, Departamento de Medicina IV, Hospital Prof. Doutor Fernando Fonseca, E.P.E, Amadora, Portugal
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Lim R, Dinsdale G, Manning J, Heal C, Murray A, Herrick AL. Mobile phone thermography of the toes in patients with systemic sclerosis-a pilot study. Rheumatol Adv Pract 2024; 8:rkae068. [PMID: 38855628 PMCID: PMC11160323 DOI: 10.1093/rap/rkae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/11/2024] [Indexed: 06/11/2024] Open
Abstract
Objectives To investigate the hypotheses that in patients with SSc, the temperature gradient between the dorsum of the foot and toes (distal-dorsal difference [DDD]) is 'more negative' (toes cooler) than in healthy controls, is greatest along the first (great) toe and that the severities of thermographic abnormalities in the feet and hands are correlated. Methods Thermographic images of the dorsum of each hand and foot were captured using a thermal camera attached to an iPhone in 40 patients with SSc and 20 healthy controls. DDDs along the fingers (index, middle, ring and little) and toes (great toe and 'others') were measured. Results There was a non-significant trend for the great toes to be colder in patients with SSc than in controls. The mean great toe DDD was more negative in patients (right: -2.89°C, left: -2.91°C, mean: -2.90°C) than in controls (right: -2.36°C, left: -2.42°C, mean: -2.39°C) (P = 0.37 for mean values). Patients' great toes were colder than 'other' (lesser) toes (right: -2.58°C, left: -2.63°C), although not significantly. In patients with SSc, finger and great toe temperature gradients were correlated (r = 0.406, ρ = 0.01). Conclusion Our findings suggest that the great toe is the coldest in patients with SSc and that patients with the coldest fingers tend to have the coldest toes. Severe RP symptoms in the hands should prompt podiatry assessment and foot care education. Mobile phone thermography is a convenient tool for assessing the digital vasculature but first requires validation in larger studies with a longitudinal component.
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Affiliation(s)
- Ruey Lim
- Centre for Musculoskeletal Research, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Graham Dinsdale
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Joanne Manning
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Calvin Heal
- Centre for Biostatistics, The University of Manchester, Manchester, UK
| | - Andrea Murray
- Centre for Musculoskeletal Research, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, UK
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Caetano J, Rodrigues LM, Alves JD. What have we learned on pre, very early, and early systemic sclerosis microcirculatory pathophysiology? A scoping review. Autoimmun Rev 2024; 23:103540. [PMID: 38604463 DOI: 10.1016/j.autrev.2024.103540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Microvascular dysfunction is an early event in the pathogenesis of systemic sclerosis (SSc). The objective of this scoping review is to update the current information and the level of knowledge about the mechanisms of microvascular dysfunction in pre-SSc, very early diagnosis of SSc (VEDOSS) and early SSc. METHODS A PubMed® database search allowed us to include original data from full-length articles in English in which the main topic was microvascular dysfunction in pre-SSC, VEDOSS or early SSc. Data was extracted using a customized form. RESULTS In the present review 437 articles were identified, and 42 studies included, reporting data from a total of 1069 patients with pre-SSc, VEDOSS or early-SSc. Distinct mechanisms of microvascular injury were identified comprising, angiogenesis and vasculogenesis, cell surface proteins and adhesion, molecules expression, cytokines profile, inflammatory and oxidation pathways, and skin perfusion determinants. Most of the studies were conducted in early SSc, with a reduced number in pre-disease stages, in which the prompt recognition of specific mechanisms and biomarkers may allow targeted treatment to prevent disease progression. CONCLUSIONS Although different molecular expression patterns and signaling pathways related to microvascular dysfunction in pre-SSc, VEDOSS, and early SSc were identified, additional prospective longitudinal studies and combined work with functional evaluation of peripheral skin perfusion are needed.
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Affiliation(s)
- Joana Caetano
- CBIOS-Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1749-024 Lisbon, Portugal; Systemic Autoimmune Diseases Unit, Department of Medicine IV, Fernando Fonseca Hospital, 2720-276 Amadora, Portugal; Nova Medical School, 1169-056 Lisboa, Portugal.
| | - Luís Monteiro Rodrigues
- CBIOS-Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1749-024 Lisbon, Portugal
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Department of Medicine IV, Fernando Fonseca Hospital, 2720-276 Amadora, Portugal; Nova Medical School, 1169-056 Lisboa, Portugal.
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Brunner-Ziegler S, Dassler E, Müller M, Pratscher M, Forstner NFFM, Koppensteiner R, Schlager O, Jilma B. Capillaroscopic differences between primary Raynaud phenomenon and healthy controls indicate potential microangiopathic involvement in benign vasospasms. Vasc Med 2024; 29:200-207. [PMID: 38334058 PMCID: PMC11010550 DOI: 10.1177/1358863x231223523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
BACKGROUND For primary Raynaud phenomenon (PRP), an otherwise unexplained vasospastic disposition is assumed. To test the hypothesis of an additional involvement of distinct ultrastructural microvascular alterations, we compared the nailfold capillary pattern of patients with PRP and healthy controls. METHODS A total of 120 patients with PRP (with a median duration of vasospastic symptoms of 60 [IQR: 3-120] months) were compared against 125 controls. In both groups, nailfold capillaroscopy was performed to record the presence of dilatations, capillary edema, tortuous capillaries, ramifications, hemorrhages, and reduced capillary density and to determine a semiquantitative rating score. Further, the capacity of finger skin rewarming was investigated by performing infrared thermography in combination with cold provocation. RESULTS Unspecific morphologic alterations were found in both, PRP, such as controls, whereby the risk for PRP was four times as high in the presence of capillary dilations (CI: 2.3-7.6) and five times as high if capillary density was reduced (CI: 1.9-13.5). Capillary density correlated with thermoregulatory capacity in both hands in the PRP group, but not in controls. In addition, a negative correlation between the microangiopathy score and the percentage degree of rewarming in both hands was found for patients with PRP only. CONCLUSION We found specific differences within the microvascular architecture between patients with PRP and controls. As a conclusion, PRP may not be an entirely benign vasospastic phenomenon, but might be associated with subtle microcirculatory vasculopathy. In addition, we suggest that the implementation of a scoring system might serve as guidance in the diagnostic process at least of patients with long-standing PRP.
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Affiliation(s)
- Sophie Brunner-Ziegler
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
- Current: Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Eva Dassler
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Markus Müller
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Marco Pratscher
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | | | - Renate Koppensteiner
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Oliver Schlager
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Current: Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Tapia-Haro RM, García-Ríos MC, Castro-Sánchez AM, Toledano-Moreno S, Casas-Barragán A, Aguilar-Ferrándiz ME. Analysis of Hand Function, Upper Limb Disability, and Its Relationship with Peripheral Vascular Alterations in Raynaud's Phenomenon. Diagnostics (Basel) 2023; 14:93. [PMID: 38201402 PMCID: PMC10795737 DOI: 10.3390/diagnostics14010093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
This study aimed to compare vascular involvement, hand functionality, and upper limb disability between Raynaud's phenomenon participants and controls. Also, we analyzed the relationships between vascular impairment, mobility, and strength with disability in this Raynaud population. We conducted a case-control study with fifty-seven participants. We registered sociodemographic and clinical data; vascular variables (temperature, cold test, blood flow, and oxygen saturation); functional variables (pinch strength, range of motion), and disability (Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire) (Q-DASH). Raynaud participants present more disability in all Q-DASH subscales, lower hands' temperature pre and post cold test, decreased blood flow on radial artery, decreased ranges of motions at passive extension of index finger, and active flexion and extension of thumb than the healthy controls. The multivariate regression analysis showed that extension of the index finger, lateral pinch strength, and oxygen saturation were significantly associated with disability in RP, almost the 55% of the total variance on the upper limb, 27% at sports/arts, and 42% at work. Our findings suggest that RP has a disabling effect on the upper extremities and a practice of activities in people who suffer it. Also, disability in Raynaud seems to be more related with hand mobility and strength impairment than vascular injury.
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Affiliation(s)
- Rosa Mª Tapia-Haro
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada (UGR), 18071 Granada, Spain; (R.M.T.-H.); (M.C.G.-R.); (A.C.-B.)
- ibs.GRANADA Instituto de Investigación Biosanitaria, 18012 Granada, Spain;
| | - Mª Carmen García-Ríos
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada (UGR), 18071 Granada, Spain; (R.M.T.-H.); (M.C.G.-R.); (A.C.-B.)
- ibs.GRANADA Instituto de Investigación Biosanitaria, 18012 Granada, Spain;
| | | | - Sonia Toledano-Moreno
- ibs.GRANADA Instituto de Investigación Biosanitaria, 18012 Granada, Spain;
- Biomedicine Program, Department of Physical Therapy, Faculty of Health Science, University of Granada (UGR), 18071 Granada, Spain
| | - Antonio Casas-Barragán
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada (UGR), 18071 Granada, Spain; (R.M.T.-H.); (M.C.G.-R.); (A.C.-B.)
- ibs.GRANADA Instituto de Investigación Biosanitaria, 18012 Granada, Spain;
| | - Mª Encarnación Aguilar-Ferrándiz
- Department of Physical Therapy, Faculty of Health Sciences, University of Granada (UGR), 18071 Granada, Spain; (R.M.T.-H.); (M.C.G.-R.); (A.C.-B.)
- ibs.GRANADA Instituto de Investigación Biosanitaria, 18012 Granada, Spain;
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Markousis-Mavrogenis G, Bournia VK, Sfikakis PP, Mavrogeni SI. Raynaud phenomenon and microvasculopathy in systemic sclerosis: multi-modality imaging for diagnosis and evaluation. Curr Opin Rheumatol 2023; 35:324-333. [PMID: 37582056 DOI: 10.1097/bor.0000000000000965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW To describe the clinical significance of and the diagnostic approach to Raynaud phenomenon (RP) in the peripheral extremities and the heart. RECENT FINDINGS Nailfold capillaroscopy has recently been standardized in an expert consensus paper. Abnormal capillaroscopy in combination with specific autoantibody profiles and clinical signs are highly predictive of progression of RP to systemic sclerosis (SSc). Magnetic resonance imaging (MRI) can also perform tissue characterization of both the extremities and the heart. Microvascular wall abnormalities detected using nailfold capillaroscopy in patients with SSc may lead to deposition of erythrocyte-derived iron, due to microhemorrhages, which may predispose to fibrosis. MRI can assess the presence of iron using T2∗ measurements. SUMMARY RP is a hallmark of the microvasculopathy in SSc and can affect both the peripheral extremities and the heart. Nailfold capillaroscopy is the current gold standard for the evaluation of the peripheral microvasculature. Other imaging modalities include thermography, laser Doppler-derived methods, 99m Tc-pertechnetate hand perfusion scintigraphy, power Doppler ultrasonography, dynamic optical coherence tomography, MRI, and photoacoustic imaging, but these are currently not widely used. Cardiac RP can be investigated with positron emission tomography or cardiovascular magnetic resonance, with the latter offering the additional possibility of tissue characterization and iron content quantification secondary to microhemorrhages.
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Affiliation(s)
- George Markousis-Mavrogenis
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital
| | | | - Petros P Sfikakis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School
| | - Sophie I Mavrogeni
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital
- Onassis Cardiac Surgery Hospital, Athens, Greece
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Eden M, Murray A, Taylor C, Herrick AL. Comment on: Nailfold capillaroscopy: a survey of current UK practice and 'next steps' to increase uptake among rheumatologists: reply. Rheumatology (Oxford) 2023; 62:e305. [PMID: 37527028 DOI: 10.1093/rheumatology/kead385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- Martin Eden
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Taylor
- Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Maltez N, Hughes M, Brown E, Hickey V, Shea B, Herrick AL, Proudman S, Merkel PA, Pauling JD. Domain reporting in systemic sclerosis-related Raynaud's phenomenon: An OMERACT scoping review. Semin Arthritis Rheum 2023; 61:152208. [PMID: 37202251 DOI: 10.1016/j.semarthrit.2023.152208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Raynaud's phenomenon (RP) is a cardinal feature of SSc and is associated with significant disease-related morbidity that impacts on quality of life. The assessment of SSc-RP is challenging. The aim of this scoping review was to evaluate the outcome domains studied and outcome measures used in clinical studies of SSc-RP. METHODS Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify randomized control trials (RCTs), quasi-randomized studies, case-control studies, prospective and retrospective cohort studies, case series, and cross-sectional studies of adult participants with SSc-associated RP, written in English. A minimum of 25 participants for studies of imaging modalities and 40 participants for questionnaire-based studies was required for inclusion. Basic laboratory and genetic studies were excluded. No limitations were imposed based on intervention, comparator, or study setting. Study characteristics and primary and secondary target domains in each study were recorded. RESULTS 58 studies (24 randomized clinical trials) were included in the final analysis. The commonest domains captured were severity of attacks (n=35), frequency of attacks (n=28), and duration of attacks (n=19). Objective assessments of digital perfusion were also commonly used in studies of SSc-RP. CONCLUSION The outcome domains and the associated outcomes used to assess the impact of SSc-RP in research studies are broad and have varied across studies. The results of this study will inform the OMERACT Vascular Disease in Systemic Sclerosis Working Group to establish a core set of disease domains encompassing the impact of RP in SSc.
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Affiliation(s)
- Nancy Maltez
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Michael Hughes
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK; Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | - Beverley Shea
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susanna Proudman
- Discipline of Medicine, University of Adelaide and Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Pauling
- North Bristol NHS Trust, Bristol, UK; Bristol Medical School, University of Bristol, Bristol, UK
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Teaw S, Gupta A, Williams A, Wilson FP, Sumpio BJ, Sumpio BE, Hinchcliff M. Hyperspectral imaging in systemic sclerosis-associated Raynaud phenomenon. Arthritis Res Ther 2023; 25:10. [PMID: 36670487 PMCID: PMC9854186 DOI: 10.1186/s13075-023-02990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND/PURPOSE Lack of robust, feasible, and quantitative outcomes impedes Raynaud phenomenon (RP) clinical trials in systemic sclerosis (SSc) patients. Hyperspectral imaging (HSI) non-invasively measures oxygenated and deoxygenated hemoglobin (oxyHb and deoxyHb) concentrations and oxygen saturation (O2 sat) in the skin and depicts data as oxygenation heatmaps. This study explored the potential role of HSI in quantifying SSc-RP disease severity and activity. METHODS Patients with SSc-RP (n = 13) and healthy control participants (HC; n = 12) were prospectively recruited in the clinic setting. Using a hand-held camera, bilateral hand HSI (HyperMed™, Waltham, MA) was performed in a temperature-controlled room (22 °C). OxyHb, deoxyHb, and O2 sat values were calculated for 78-mm2 regions of interest for the ventral fingertips and palm (for normalization). Subjects underwent a cold provocation challenge (gloved hand submersion in 15 °C water bath for 1 min), and repeated HSI was performed at 0, 10, and 20 min. Patients completed two patient-reported outcome (PRO) instruments: the Raynaud Condition Score (RCS) and the Cochin Hand Function Scale (CHFS) for symptom burden assessment. Statistical analyses were performed using the Mann-Whitney U test and a mixed effects model (Stata, College Station, TX). RESULTS Ninety-two percent of participants were women in their 40s. For SSc-RP patients, 69% had limited cutaneous SSc, the mean ± SD SSc duration was 11 ± 5 years, and 38% had prior digital ulcers-none currently. Baseline deoxyHb was higher, and O2 sat was lower, in SSc patients versus HC (p < 0.05). SSc patients had a greater decline in oxyHb and O2 sat from baseline to time 0 (after cold challenge) with distinct rewarming oxyHb, O2 sat, and deoxyHb trajectories versus HCs (p < 0.01). There were no significant correlations between oxyHb, deoxyHb, and O2 sat level changes following cold challenge and RCS or CHFS scores. CONCLUSION Hyperspectral imaging is a feasible approach for SSc-RP quantification in the clinic setting. The RCS and CHFS values did not correlate with HSI parameters. Our data suggest that HSI technology for the assessment of SSc-RP at baseline and in response to cold provocation is a potential quantitative measure for SSc-RP severity and activity, though longitudinal studies that assess sensitivity to change are needed.
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Affiliation(s)
- Shannon Teaw
- Section of Rheumatology, Allergy & Immunology, Department of Medicine, Yale School of Medicine, 300 Cedar Street, The Anlyan Center PO Box 208031, New Haven, CT, 06520, USA
| | - Akash Gupta
- Section of Rheumatology, Allergy & Immunology, Department of Medicine, Yale School of Medicine, 300 Cedar Street, The Anlyan Center PO Box 208031, New Haven, CT, 06520, USA
| | - Alyssa Williams
- Section of Rheumatology, Allergy & Immunology, Department of Medicine, Yale School of Medicine, 300 Cedar Street, The Anlyan Center PO Box 208031, New Haven, CT, 06520, USA
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bauer E Sumpio
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Monique Hinchcliff
- Section of Rheumatology, Allergy & Immunology, Department of Medicine, Yale School of Medicine, 300 Cedar Street, The Anlyan Center PO Box 208031, New Haven, CT, 06520, USA.
- Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
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Pacini G, Pogna A, Pendolino M, Pizzorni C, Carmisciano L, Gotelli E, Sulli A, Paolino S, Schenone C, Smith V, Cutolo M. Understanding the value of non-specific abnormal capillary dilations in presence of Raynaud's phenomenon: a detailed capillaroscopic analysis. RMD Open 2022; 8:rmdopen-2022-002449. [PMID: 36197673 PMCID: PMC9462093 DOI: 10.1136/rmdopen-2022-002449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/22/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Nailfold videocapillaroscopy (NVC) non-specific abnormalities may be present in subjects with isolated Raynaud's phenomenon (RP) before the potential transition to systemic sclerosis (SSc) specific microvascular alterations ('scleroderma pattern'). This study aims to investigate NVC non-specific abnormalities, notably capillary dilations, in RP patients, as possible forerunners of the 'scleroderma pattern'. METHODS A 10-year retrospective NVC-based investigation evaluated 55 RP patients sorted into 3 sex-matched and age-matched groups according to clinical evolution: 18 later developing SSc (cases), 19 later developing other connective tissue disease and 18 maintaining primary RP at long-term follow-up (controls). All patients had a basal NVC showing non-specific abnormalities, namely non-specific >30 µm dilated capillaries (30-50 μm diameter). Sequential NVCs were longitudinally evaluated using current standardised approach. Statistical analysis assessed the risk for developing a 'scleroderma pattern'. RESULTS Significantly larger capillary diameters were observed in cases versus controls both at basal NVC and during follow-up NVC (p=<0.05 to <0.001). Interestingly, controls showed stable NVC non-specific abnormalities over the study follow-up. The number of >30 µm dilated capillaries/mm at basal NVC was the strongest single predictor of 'scleroderma pattern' evolution with 24% increased risk per each dilated capillary (OR 1.24, 95% CI 1.17,1.32). Additionally, a tree-based analysis suggested the efferent (venous) diameter of the most dilated capillary on basal NVCas a variable of interest to identify patients maintaining primary RP. CONCLUSION This is the first study to describe an NVC 'prescleroderma signature' to potentially identify RP patients later developing a 'scleroderma pattern'.
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Affiliation(s)
- Greta Pacini
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Andrea Pogna
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Monica Pendolino
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Carmisciano
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Department of Rheumatology, University Hospital Ghent, Gent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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12
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Ramahi A, Hughes M, Khanna D. Practical management of Raynaud's phenomenon - a primer for practicing physicians. Curr Opin Rheumatol 2022; 34:235-244. [PMID: 35699336 PMCID: PMC9246963 DOI: 10.1097/bor.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Raynaud's phenomenon (RP) is a common vasospastic condition that results in digital hypoperfusion in response to cold and/or emotional stress and is associated with significant pain and disability. The aim of our review is to provide a practical approach for clinicians to inform assessment and management of patients with RP. RECENT FINDINGS Autoantibodies and nailfold capillaroscopy are key investigations to stratify the risk of progression to systemic sclerosis (SSc) in patients RP, which was recently confirmed in the multicenter, very early diagnosis of systemic sclerosis (VEDOSS) project. Research has explored the complex lived-patient experience of RP including digital vasculopathy in SSc and has highlighted the need for outcome measure development to facilitate research in the field. Pharmacological treatment strategies vary significantly internationally and there is continued interest in developing surgical approaches. SUMMARY We provide a practical and up-to-date approach to inform the assessment and management of patients with RP including guidance on drug initiation and escalation. Calcium channel blockers are first-line treatment and can be initiated by primary care physicians. We also highlight second-line drug therapies used for refractory RP and the potential role for surgical intervention.
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Affiliation(s)
- Ahmad Ramahi
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Michael Hughes
- Tameside Hospital, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, United Kingdom
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
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Maciejewska M, Sikora M, Maciejewski C, Alda-Malicka R, Czuwara J, Rudnicka L. Raynaud's Phenomenon with Focus on Systemic Sclerosis. J Clin Med 2022; 11:jcm11092490. [PMID: 35566614 PMCID: PMC9105786 DOI: 10.3390/jcm11092490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
Raynaud’s phenomenon is a painful vascular condition in which abnormal vasoconstriction of the digital arteries causes blanching of the skin. The treatment approach can vary depending on the underlying cause of disease. Raynaud’s phenomenon can present as a primary symptom, in which there is no evidence of underlying disease, or secondary to a range of medical conditions or therapies. Systemic sclerosis is one of the most frequent causes of secondary Raynaud’s phenomenon; its appearance may occur long before other signs and symptoms. Timely, accurate identification of secondary Raynaud’s phenomenon may accelerate a final diagnosis and positively alter prognosis. Capillaroscopy is fundamental in the diagnosis and differentiation of primary and secondary Raynaud’s phenomenon. It is helpful in the very early stages of systemic sclerosis, along with its role in disease monitoring. An extensive range of pharmacotherapies with various routes of administration are available for Raynaud’s phenomenon but a standardized therapeutic plan is still lacking. This review provides insight into recent advances in the understanding of Raynaud’s phenomenon pathophysiology, diagnostic methods, and treatment approaches.
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Affiliation(s)
- Magdalena Maciejewska
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Mariusz Sikora
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
- Correspondence:
| | - Cezary Maciejewski
- 1st Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Rosanna Alda-Malicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Joanna Czuwara
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Koszykowa 82A, 02-008 Warsaw, Poland; (M.M.); (R.A.-M.); (J.C.); (L.R.)
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14
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Sirufo MM, Magnanimi LM, Ginaldi L, De Martinis M. The shadow zone of capillaroscopy in the classification of the Raynaud's phenomenon. Curr Med Res Opin 2022; 38:637-639. [PMID: 35227144 DOI: 10.1080/03007995.2022.2047538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Raynaud's phenomenon (RP) is a frequent clinical finding in the general population that can be observed across multiple medical specialties and nailfold videocapillaroscopy is a first line imaging tool to early differenziate primitive and secondary forms of RP. According to the criteria of LeRoy and Medsger normal nailfold capillaries characterize a primary RP. The recognition of vascular alterations at capillaroscopy is the key to a correct framing of the phenomenon. Capillaroscopy is of significant practical value as it allows a reliable predictive assessment of the developmental risk of the disorder. However, to date, the variety of nomenclature for subjects affected by RP generates uncertainty in patient management and in the possibility of comparing studies. The capillaroscopic findings have a very broad range of normality and a significant presence of non specific microvascular abnormalities are reported also in patients with primary RP. The presence of these non specific vascular changes can make it difficult to differenziate primary and secondary RP. Here we highlight some critical points in the capillaroscopic distinction of primary and secondary RP and relaunch the debate on the classification of the RP because it is likely that what we identify today as the primary RP (pRP) collects different clinical entities with different prognostic significance and different therapeutic needs.
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Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
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15
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Nawaz I, Nawaz Y, Nawaz E, Manan MR, Mahmood A. Raynaud's Phenomenon: Reviewing the Pathophysiology and Management Strategies. Cureus 2022; 14:e21681. [PMID: 35242466 PMCID: PMC8884459 DOI: 10.7759/cureus.21681] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/25/2022] [Indexed: 12/27/2022] Open
Abstract
Raynaud's phenomenon (RP) is a multifactorial vasospastic disorder characterized by a transient, recurrent, and reversible constriction of peripheral blood vessels. RP is documented to affect up to 5% of the general population, but variation in its prevalence is commonly recognized owing to many factors, including varied definitions, gender, genetics, hormones, and region. Furthermore, RP may be idiopathic or be a clinical manifestation of an underlying illness. Patients with RP classically describe a triphasic discoloration of the affected area, beginning with pallor, followed by cyanosis, and finally ending with erythema. This change in color spares the thumb and is often associated with pain. Each attack may persist from several minutes to hours. Moreover, the transient cessation of blood flow in RP is postulated to be mediated by neural and vascular mechanisms. Both structural and functional alterations observed in the blood vessels contribute to the vascular abnormalities documented in RP. However, functional impairment serves as a primary contributor to the pathophysiology of primary Raynaud's. Substances like endothelin-1, angiotensin, and angiopoietin-2 play a significant role in the vessel-mediated pathophysiology of RP. The role of nitric oxide in the development of this phenomenon is still complex. Neural abnormalities resulting in RP are recognized as either being concerned with central mechanisms or peripheral mechanisms. CNS involvement in RP may be suggested by the fact that emotional distress and low temperature serve as major triggers for an attack, but recent observations have highlighted the importance of locally produced factors in this regard as well. Impaired vasodilation, increased vasoconstriction, and several intravascular abnormalities have been documented as potential contributors to the development of this disorder. RP has also been observed to occur as a side effect of various drugs. Recent advances in understanding the mechanism of RP have yielded better pharmacological therapies. However, general lifestyle modifications along with other nonpharmacological interventions remain first-line in the management of these patients. Calcium channel blockers, alpha-1 adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors, nitric oxide, prostaglandin analogs, and phosphodiesterase inhibitors are some of the common classes of drugs that have been found to be therapeutically significant in the management of RP. Additionally, anxiety management, measures to avoid colder temperatures, and smoking cessation, along with other simple modifications, have proven to be effective non-drug strategies in patients experiencing milder symptoms.
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Affiliation(s)
- Iqra Nawaz
- Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | | | - Eisha Nawaz
- Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | | | - Adil Mahmood
- Medicine, Bahawal Victoria Hospital, Bahawalpur, PAK
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16
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Detection of microvascular changes in systemic sclerosis and other rheumatic diseases. Nat Rev Rheumatol 2021; 17:665-677. [PMID: 34561652 DOI: 10.1038/s41584-021-00685-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 02/08/2023]
Abstract
Morphological and functional analysis of the microcirculation are objective outcome measures that are recommended for use in the presence of clinical signs of altered peripheral blood flow (such as Raynaud phenomenon), which can occur in systemic sclerosis (SSc) and other autoimmune rheumatic diseases. Several advanced non-invasive tools are available for monitoring the microcirculation, including nailfold videocapillaroscopy, which is the best-studied and most commonly used method for distinguishing and quantifying microvascular morphological alterations in SSc. Nailfold videocapillaroscopy can also be used alongside laser Doppler techniques to assist in the early diagnosis and follow-up of patients with dermatomyositis or mixed connective tissue disease. Power Doppler ultrasonography, which has been used for many years to evaluate the vascularity of synovial tissue in rheumatoid arthritis, is another promising tool for the analysis of skin and nailbed capillary perfusion in other autoimmune rheumatic diseases. Other emerging methods include raster-scanning optoacoustic mesoscopy, which offers non-invasive high-resolution 3D visualization of capillaries and has been tested in psoriatic arthritis and SSc. The principle functions and operative characteristics of several non-invasive tools for analysing microvascular changes are outlined in this Review, and the clinical roles of validated or tested imaging methods are discussed for autoimmune rheumatic diseases.
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Abstract
PURPOSE OF REVIEW The aim of this review is to give an update on advances in evaluation and management of systemic sclerosis (SSc)-related Raynaud's phenomenon and digital ulceration, focusing on reports from the last 18 months. The increasing recognition of the huge impact of Raynaud's phenomenon and of digital ulceration on the everyday lives of patients with SSc has sparked enthusiasm internationally to develop better outcome measures and better treatments, and so a review is timely. RECENT FINDINGS There have been recent advances in the development of patient reported outcome instruments [e.g. the Hand Disability in Systemic Sclerosis-Digital Ulcers (HDISS-DU) instrument] and also in noninvasive imaging techniques, including thermography and laser Doppler methods. Improved outcome measures will facilitate future clinical trials, both early phase proof-of-concept and later phase trials. New insights have been gained into mechanisms of action and methods of administration of 'conventional' therapies, for example phosphodiesterase inhibitors and intravenous prostanoids. New treatment approaches are being investigated, including topical and procedural therapies. SUMMARY Clinicians can look forward to seeing these advances translating into clinical benefit over the next 5 years. To help ensure this, they should strive whenever possible to recruit patients with SSc-related digital vasculopathy into observational studies and clinical trials.
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18
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Herrick AL, Heal C, Wilkinson J, Dinsdale G, Manning J, Gunnarsson K, Jakobsson PJ, Murray A. Temperature response to cold challenge and mobile phone thermography as outcome measures for systemic sclerosis-related Raynaud's phenomenon. Scand J Rheumatol 2021; 50:479-484. [PMID: 34132168 DOI: 10.1080/03009742.2021.1907926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objectives: Objective outcome measures of systemic sclerosis (SSc)-related Raynaud's phenomenon (RP) are badly needed. Our objectives were to validate the thermographic response to a standard hand cold challenge as an outcome measure by assessing sensitivity to change, and to explore mobile phone thermography as a feasible, ambulatory tool.Method: Twelve patients with an SSc-spectrum disorder admitted for intravenous iloprost infusions underwent a standard cold challenge before and after one infusion. Thermographic measurements included area under the rewarming curve (AUC) and maximum rewarming temperature (MAX). Before and during another infusion, each patient underwent monitoring of finger skin temperature by two methods: continuous thermocouple recording (standard method) and mobile phone thermography.Results: All cold challenge summary measures, including AUC and MAX, increased after iloprost (most not significantly). However, when the response curves were modelled after averaging across fingers (linear mixed models, three versions), significant change was detected. For example, with Model 1 (no interaction between period and time), temperature was on average 1.67ºC [95% confidence interval (CI) 1.49-1.85, p < 0.001] higher post-iloprost. Mobile phone and thermocouple temperature measurements showed a strong estimated latent correlation (0.88, 95% CI 0.81-0.92). The estimated increases/hour were 0.25ºC (95% CI 0.05-0.45) for the thermocouple and 0.36ºC (95% CI 0.13-0.60) for mobile phone thermography.Conclusion: Our pilot study suggests that the thermographic response to a cold challenge is sensitive to change and mobile phone thermography could bring feasibility to thermographic parameters as outcome measures in later-phase, large-scale, community-based clinical trials of RP.
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Affiliation(s)
- A L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - C Heal
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - J Wilkinson
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - G Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - J Manning
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - K Gunnarsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P-J Jakobsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Murray
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Aleksiev T, Ivanova Z, Dobrev H, Atanasov N. Application of a novel finger temperature device in the assessment of subjects with Raynaud's phenomenon. Skin Res Technol 2021; 27:1110-1115. [PMID: 34080745 DOI: 10.1111/srt.13070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/06/2021] [Accepted: 05/14/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Finger skin thermometry is one of the most commonly used methods for evaluating the response of the digital vessels to cold stimulation. The aim of this study was to evaluate the applicability of a novel finger skin temperature device for performing cold-stimulation test (CST) in subjects with primary and secondary Raynaud's phenomenon (RP). METHODOLOGY A total of 155 consecutive subjects were studied. They were divided into three groups: 73 patients with primary RP (8 males, 65 females, mean age 38.5 ± 16.2), 42 patients with secondary RP (4 males, 38 females, mean age 49.6 ± 13.1, connected with lupus erythematosus and systemic scleroderma), and 40 healthy controls (5 males, 35 females, mean age 38.8 ± 16.6). Standardized CST consisting of exposure of both hands to water with a temperature of 10℃ for 5 minutes was performed. Changes in skin temperature of both wrists and 2-5 fingers were measured using a novel finger temperature device (Courage & Khazaka). Measurements were made before and 5, 10, 15, 20, 25, and 30 minutes after cold stimulation. The time of recovery for baseline temperature of all fingers below 15 minutes was considered normal. RESULTS The CST was normal in 6 (8.2%) of the patients with primary RP, in 7 (16.6%) of the patients with secondary RP, and in 28 (70%) of the healthy control subjects. The time of complete recovery of baseline temperature with respect to the first finger and for all 2-5 fingers in the three groups was as follows: 24.8 and 28.5 minutes (primary RP), 21.7 and 26.8 minutes (secondary RP), and 11.1 and 15.2 minutes (healthy subjects). Furthermore, the microcirculation was seriously disturbed (rewarming time >31 minutes of all 2-5 digits of both hands) in 54.1% (n = 79), 34.5% (n = 29) and 5% (n = 4) in the same study groups. DISCUSSION Our results suggested that skin microcirculation is more disturbed in patients with primary RP than in patients with secondary RP. In support of this unexpected finding were the results reported by Ruaro B. et al (2019). They investigated the blood perfusion (BP) by laser speckle contrast analysis (LASCA) at different skin areas of hands and found that it was significantly lower in primary RP than in secondary RP related to systemic sclerosis. CONCLUSION The new finger temperature device used could be considered useful for performing cold-stimulation test in patients with Raynaud's phenomenon.
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Affiliation(s)
- Teodor Aleksiev
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Zlatina Ivanova
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Hristo Dobrev
- Department of Dermatology and Venereology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Nikolay Atanasov
- Department of Health Management and Health Economics, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
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Herrick AL, Berks M, Taylor CJ. Quantitative nailfold capillaroscopy-update and possible next steps. Rheumatology (Oxford) 2021; 60:2054-2065. [PMID: 33493310 DOI: 10.1093/rheumatology/keab006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 11/14/2022] Open
Abstract
We review the exciting potential (and challenges) of quantitative nailfold capillaroscopy, focusing on its role in systemic sclerosis. Quantifying abnormality, including automated analysis of nailfold images, overcomes the subjectivity of qualitative/descriptive image interpretation. First we consider the rationale for quantitative analysis, including the potential for precise discrimination between normal and abnormal capillaries and for reliable measurement of disease progression and treatment response. We discuss nailfold image acquisition and interpretation, and describe how early work on semi-quantitative and quantitative analysis paved the way for semi-automated and automated analysis. Measurement of red blood cell velocity is described briefly. Finally we give a personal view on 'next steps'. From a clinical perspective, increased uptake of nailfold capillaroscopy by general rheumatologists could be achieved via low-cost hand-held devices with cloud-based automated analysis. From a research perspective, automated analysis could facilitate large-scale prospective studies using capillaroscopic parameters as possible biomarkers of systemic sclerosis-spectrum disorders.
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Affiliation(s)
- Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Chris J Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
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21
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Convolutional Neural Networks for Differential Diagnosis of Raynaud’s Phenomenon Based on Hands Thermal Patterns. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11083614] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Raynaud’s phenomenon (RP) is a microvessels’ disorder resulting in transient ischemia. It can be either primary or secondary to connective tissue diseases, such as systemic sclerosis. The differentiation between primary and secondary to systemic sclerosis is of paramount importance to set the proper therapeutic strategy. Thus far, thermal infrared imaging has been employed to accomplish this task by monitoring the finger temperature response to a controlled cold challenge. A completely automated methodology based on deep convolutional neural network is here introduced with the purpose of being able to differentiate systemic sclerosis from primary RP patients by relying uniquely on thermal images of the hands acquired at rest. The classification performance of such a method was compared to that of a three-dimensional convolutional neural network model implemented to classify thermal images of the hands recorded during rewarming from a cold challenge. No significant differences were found between the two procedures, thus ensuring the possibility to avoid the cold challenge. Moreover, the convolutional neural network models were compared with standard feature-based approaches and showed higher performances, thus overcoming the limitations related to the feature extraction (e.g., biases introduced by the operator). Such automated procedures can constitute promising tools for large scale screening of primary RP and secondary to systemic sclerosis in clinical practice.
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22
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Characteristic Features of Infrared Thermographic Imaging in Primary Raynaud's Phenomenon. Diagnostics (Basel) 2021; 11:diagnostics11030558. [PMID: 33804657 PMCID: PMC8003729 DOI: 10.3390/diagnostics11030558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
Raynaud’s phenomenon (RP) is characterized by the episodic whitening of the fingers upon exposure to cold. Verification of the condition is crucial in vibration-exposed patients. The current verification method is outdated, but thermographic imaging seems promising as a diagnostic replacement. By investigating patients diagnosed with RP, the study aimed at developing a simple thermographic procedure that could be applied to future patients where verification of the diagnosis is needed. Twenty-two patients with primary RP and 58 healthy controls were examined using thermographic imaging after local cooling of the hands for 1 min in water of 10°C. A logistic regression model was fitted with the temperature curve characteristics to convey a predicted probability of having RP. The characteristics time to end temperature and baseline temperature were the most appropriate predictors of RP among those examined (p = 0.004 and p = 0.04, respectively). The area under the curve was 0.91. The cut-off level 0.46 yielded a sensitivity and specificity of 82% and 86%, respectively. The positive and negative predictive values were 69% and 93%, respectively. This newly developed thermographic method was able to distinguish between patients with RP and healthy controls and was easy to operate. Thus, the method showed great promise as a method for verification of RP in future patients. Trial registration: ClinicalTrials.gov NCT03094910.
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