Raynaud's phenomenon-an update on diagnosis, classification and management

Raynaud's phenomenon (RP) is used to describe a symptom complex caused by digital vascular compromise. RP is a clinical diagnosis. The typically episodic nature of RP has resulted in a reliance upon patient self-report for diagnosis. The term 'primary RP' is generally applied when no underlying pathology can be demonstrated. Whilst 'primary RP' is currently considered a distinct disorder, there is evidence that the term may comprise several entities that include a functional vasospastic disorder, a physiologically appropriate thermoregulatory response, subclinical atherosclerosis and 'cold intolerance'. Optimal management may differ depending on cause. The term 'secondary RP' encompasses a broad range of rheumatological, haematological, endocrinological and vascular pathology. RP can range from relatively benign but intrusive vasospasm, to the progressive obliterative microangiopathy of systemic sclerosis (SSc), in which severe digital ischaemia can threaten tissue viability. SSc has formed the focus of much of the research into RP but, consistent with most medical symptom complexes, the aetiopathogenesis of RP varies greatly dependent on cause. Vasospasm within the digital macro- and microvasculature occurs in SSc, but digital ischaemia is further compounded by a progressive obliterative microangiopathy. Recent work exploring the patient experience of SSc-RP is challenging the 'episodic' paradigm of 'Raynaud's', with important implications for clinical trials utilising diary-based patient-reported outcome instruments for assessing Raynaud's symptoms. This review shall examine the causes, pathogenesis, clinical features, classification and management of RP. A practical approach to the evaluation and management of RP is outlined, highlighting important knowledge gaps and unmet research needs where applicable. Key Points • Raynaud's phenomenon is a symptom complex related to digital vascular compromise secondary to broad-ranging pathology. • Raynaud's phenomenon, as currently classified, likely encompasses a number of aetiopathogenic processes. • Raynaud's phenomenon causes significant disease-related morbidity in autoimmune rheumatic diseases such as systemic sclerosis.

A Delphi exercise and cluster analysis to aid in the development of potential classification criteria for systemic sclerosis using SSc experts and databases

OBJECTIVES

Since the 1980 ACR classification criteria for systemic sclerosis (SSc) do not identify 20% with SSc, revised criteria are necessary.

METHODS

Suggested new criteria from the literature were sent in random order to 96 SSc experts. A 3-round Delphi Consensus eliminated criteria. Then cluster analysis reduced items. The Canadian Scleroderma Research Group (CSRG) database was used to determine the prevalence of each item.

RESULTS

Seventy-one of 96 (71%) completed all 3 rounds; 47 items were expanded to 76 in round 2. Thirty items had at least 50% consensus and 18 had >75% agreement to include (a priori cut point). Clustering occurred for 4 categories: proximal to MCP skin involvement, vascular abnormalities, autoantibodies and tissue damage. Proximal to MCPs skin involvement identified 80% of patients. Adding one item from each of the other 3 categories or 1 or more items from 2 of 3 remaining categories increased the proportion of patients classified to 94% in CSRG patients. Categories included (1) Vascular (dilated capillaries, telangiectasia, Raynaud's phenomenon [RP]), (2) Autoantibodies (anticentromere [ACA] or antitopoisomeraseI [Topo1]) and (3) Fibrosis/damage (esophogeal dysmotility dysphagia, sclerodactyly, digital ulcers). In the CSRG, 98% were identified if using proximal skin involvement; or sclerodactyly plus one of: RP, ACA or Topo1.

CONCLUSIONS

This is a first step toward developing new SSc classification criteria. A Delphi exercise alone cannot suffice for item reduction. Also, validation prospectively in SSc patients and diseases that mimic SSc is needed in order to calculate sensitivity and specificity of future criteria.

[Raynaud's phenomenon]

Raynaud's phenomenon is a vascular acrosyndrome caused by a variety of diseases. There is a distinction between the idiopathic Raynaud's disease, the secondary types and the suspicious idiopathic Raynaud's phenomenon.

Validation of potential classification criteria for systemic sclerosis

OBJECTIVE

Classification criteria for systemic sclerosis (SSc; scleroderma) are being updated jointly by the American College of Rheumatology and European League Against Rheumatism. Potential items for classification were reduced to 23 using Delphi and nominal group techniques. We evaluated the face, discriminant, and construct validity of the items to be further studied as potential criteria.

METHODS

Face validity was evaluated using the frequency of items in patients sampled from the Canadian Scleroderma Research Group, 1000 Faces of Lupus, and the Pittsburgh, Toronto, Madrid, and Berlin connective tissue disease (CTD) databases. Patients with SSc (n = 783) were compared to 1,071 patients with diseases similar to SSc (mimickers): systemic lupus erythematosus (n = 499), myositis (n = 171), Sjögren's syndrome (n = 95), Raynaud's phenomenon (RP; n = 228), mixed CTD (n = 29), and idiopathic pulmonary arterial hypertension (PAH; n = 49). Discriminant validity was evaluated using odds ratios (ORs). For construct validity, empirical ranking was compared to expert ranking.

RESULTS

Compared to mimickers, patients with SSc were more likely to have skin thickening (OR 427); telangiectasias (OR 91); anti-RNA polymerase III antibody (OR 75); puffy fingers (OR 35); finger flexion contractures (OR 29); tendon/bursal friction rubs (OR 27); anti-topoisomerase I antibody (OR 25); RP (OR 24); fingertip ulcers/pitting scars (OR 19); anticentromere antibody (OR 14); abnormal nailfold capillaries (OR 10); gastroesophageal reflux disease symptoms (OR 8); antinuclear antibody, calcinosis, dysphagia, and esophageal dilation (all OR 6); interstitial lung disease/pulmonary fibrosis (OR 5); and anti-PM-Scl antibody (OR 2). Reduced carbon monoxide diffusing capacity, PAH, and reduced forced vital capacity had ORs of <2. Renal crisis and digital pulp loss/acroosteolysis did not occur in SSc mimickers (OR not estimated). Empirical and expert ranking were correlated (Spearman's ρ = 0.53, P = 0.01).

CONCLUSION

The candidate items have good face, discriminant, and construct validity. Further item reduction will be evaluated in prospective SSc and mimicker cases.

Raynaud's phenomenon

Raynauds phenomena (RP) is a commonly encountered clinical manifestation which may be primary or secondary to underlying disease. There is imbalance between vasoconstricting and vasodilating factors. Physical examination, nailfold capillaroscopy and immunological tests can differentiate primary from secondary RP. Treatment involves prevention of RP so that permanent ischemic damage i.e. gangrene can be avoided. Avoidance of exposure to cold, emotional stress and certain drugs is mandatory and if attacks are occurring then vasodilators, prostaglandin analogues, anticoagulants and antiplatelet drugs may be added. An attempt has been made to guide the clinician to diagnose and treat a patient of RP through this article.

[Systemic sclerosis - diagnosis and classification]

Systemic sclerosis (SSc) is a polymorphic and heterogenic systemic disorder with inflammation, fibrosis and vascular damage. Early diagnosis and classification may be difficult if disease expression is oligosymptomatic (undifferentiated), presenting with only Raynaud's phenomenon or limited scleroderma. Scleroderma specific antinuclear autoantibodies, which are present early and persistently in about 90% of the patients with SSc, play an important taxonomic role. Scleroderma specific findings in nailfold capillary microscopy are sensitive and predictive for evolving SSc. An algorithm will be presented for the diagnosis and classification of SSc using clinical, capillaroscopic and serologic criteria, which are also useful for mixed or special forms of SSc. The 6th Outcome Measures in Rheumatology Clinical Trials (OMERACT) conference proposed different outcome measurements for clinical studies, however, for daily clinical practice there is as yet no consensus on status indices for disease activity, disease related damage or suitable prognostic criteria.

Pathophysiology and clinical consequences of Raynaud's phenomenon related to systemic sclerosis

According to the so-called vascular hypothesis, Raynaud's phenomenon (RP) is one initial event in the pathophysiological cascade leading to sclerosis in systemic sclerosis (SSc). It is characterized by recurrent, reversible spasms of small arterioles and digital arteries, usually triggered by cold and emotional stress. Clinical signs of RP are a sudden pallor of single digits of fingers followed by reactive hyperaemia and in severe cases also by cyanosis. Besides imbalances between vasoconstrictive and vasodilatory processes, structural alterations of the involved vessels are fundamental to secondary RP in SSc. The latter is the reason why secondary RP in SSc, in contrast to primary RP, often leads to ischaemia and re-perfusion injuries. New insights into the pathophysiology of RP feature a special role for alpha2c-adrenoreceptors, Rho-kinase signalling pathways and soluble mediators. They have resulted in promising therapeutic options, including antagonism of endothelin receptors, inhibition of phosphodiesterases or selective blockade of alpha2c-adrenoreceptors. They should also have a positive impact on the course of SSc in general.

Transition from primary Raynaud's phenomenon to secondary Raynaud's phenomenon identified by diagnosis of an associated disease: results of ten years of prospective surveillance

OBJECTIVE

To assess the early signs, risk factors, and rate of transition from primary Raynaud's phenomenon (primary RP) to secondary RP.

METHODS

A clinical sample of 307 consecutive patients with RP was included in a prospective followup study. After an initial screening, 244 patients were classified as having primary RP, of whom 236 were followed up for a mean +/- SD of 11.2 +/- 3.9 years. Patients classified according to the screening as having suspected secondary RP underwent an extended screening program annually until transition to secondary RP occurred.

RESULTS

The initial prevalence of secondary RP was 11%. The annual incidence of transition to suspected secondary RP was 2%, and the annual incidence of transition to secondary RP was 1%. Overall, 46 patients were classified as having suspected secondary RP, and 23 of these later were classified as having secondary RP. Older age at onset of RP (hazard ratio 2.59, 95% confidence interval [95% CI] 1.40-4.80), shorter duration of RP at enrollment (hazard ratio 0.87, 95% CI 0.81-0.94), and abnormal findings on thoracic outlet test (hazard ratio 2.69, 95% CI 1.12-6.48) were associated with an increased risk for transition to secondary RP. Compared with patients with suspected secondary RP, those diagnosed as having secondary RP had a higher number and earlier occurrence of pathologic findings. Furthermore, antinuclear antibodies at a titer of > or = 1:320 and positive findings in specific serologic subsets were associated with a significantly increased risk for developing a connective tissue disease.

CONCLUSION

Patients diagnosed initially as having primary RP may actually comprise 1 of 3 groups: those with idiopathic RP, those with a rather benign disease course, and those with a more severe course of the disease.

Raynaud phenomenon

Raynaud phenomenon, a vascular disorder triggered by cold or emotional stress, results from an exaggerated vasoconstriction and vasospasm of the digital arteries and arterioles. The fingers, and, less often, the toes, are affected; ear lobes, lips, nose, and nipples may also be involved. This article describes the difference between primary and secondary Raynaud phenomenon and reviews etiology, diagnosis, prevention, and management of symptoms.

Microcirculatory and clinical effects of serial percutaneous application of carbon dioxide in primary and secondary Raynaud’s phenomenon

Background: A randomized double-blind monocentric trial was conducted at the spa of Royat, France, in patients with mild Raynaud’s phenomenon (one or two attacks a day during the autumn and winter months). Hemodynamic changes were quantified by laser Doppler flow (LDF) and computerized chronothermometric test (CT) during local application of CO2 and compared with the usual clinical parameters. Patients and methods: Patients were randomized to 18 days of CO2 (group 1) or 9 days of air + 9 days of CO2 (group 2). The gas was applied at a constant temperature to previously humidified skin on the forearm. Effects of the active treatment were measured by LDF and continuing benefits by computerized chronothermometric test (CT test). Clinical assessment was made on four occasions (before, in the middle and at the end of treatment, and three months afterwards) on the basis of the number of daily attacks and the duration and severity of the attacks. Results: LDF showed a significant increase in digital blood flow (+ 41%) and in vasomotion (+ 42%) during CO2 treatment but no change on placebo treatment. CT test showed a comparable response to cold in the two groups during treatment. Three months later, however, warming time was significantly decreased (by 7 minutes: 25%) and warming rate increased (+ 22,4%) in group 1 (intergroup difference: p = 0,02). There was no difference between groups in the weekly number of attacks during treatment periods. In contrast there was a moderate increase in both groups in the winter months. There was no increase in the severity of the attacks nor in their duration. Conclusion: In this clinical trial, LDF evidenced positive effects of percutaneous application of natural CO2 gas on vasomotricity and vasomotion while CT test showed that patients who had received 18 days of CO2 adapted more easily to exposure to cold. Clinical improvement seems to be masked by winter weather conditions.

Microcirculation of the fingers in Raynaud's syndrome: (99m)Tc-DTPA imaging

AIM

We investigated the circulatory characteristics of patients suffering of primary and secondary Raynaud's syndrome.

PATIENTS, METHODS

We examined 106 patients presenting with the classical symptoms of Raynaud's syndrom (47 primary, 59 secondary) by hand perfusion scintigraphy developed by our Department of Nuclear Medicine. After visual evaluation we analyzed the images semiquantitatively, using the finger to palm ratio. We statistically compared the patients with primary and those with secondary Raynaud's syndrome.

RESULTS

By visual evaluation we constated regional perfusion disturbances in 42 from 59 patients with secondary Raynaud's syndrome. However, this was observed in only 3 from 47 patients with the primary form of this disease. This difference was statistically significant (p<0.001). Semiquantitative analysis showed that the finger/palm ratios (FPR) were significantly lower (p<0.05) for the patients with primary Raynaud's syndrome. No differences in the FPR values concerning sex or right and left side.

CONCLUSION

The hand perfusion scintigraphy with (99m)Tc-DTPA is a noninvasive, cost effective diagnostic tool, which objectively reflects the global and regional microcirculatory abnormalities of the hands, and provides quantitative data for follow-up.

Use of thermographic criteria to identify Raynaud's phenomenon in a population setting

OBJECTIVE

To assess the value of thermographic measurements of digital skin temperature after cold challenge in classifying Raynaud's phenomenon (RP) in a healthy population.

METHODS

One hundred seventy-five patients with RP and 404 controls were subjected to a 15 degrees C, 60 s cold challenge test. All participants were women. Digital temperature measurements were taken at baseline, immediately postimmersion, and 10 min after immersion using a portable radiometer.

RESULTS

Baseline skin temperature was a significant predictor of RP; however, the fall in temperature on immersion and the subsequent rewarming rate provided no additional information.

CONCLUSION

Baseline skin temperature can help to predict the occurrence of RP in patients drawn from the general population, but has relatively low discriminatory power. The cold challenge test itself is of limited additional value for classification. Although objective temperature measurements show little power overall to discriminate between RP and non-RP patients, detecting low baseline digital temperature may be a useful adjunct to clinical history in classifying the disease.

The clinical grading of Raynaud's phenomenon and vibration-induced white finger: relationship between finger blanching and difficulties in using the upper limb

OBJECTIVES

To investigate the association between functional difficulties in using the upper limb and extent and frequency of finger blanching, and the merits of these markers in grading the severity of Raynaud's phenomenon (RP) and vibration-induced white finger (VWF).

METHODS

A questionnaire was mailed to a randomly selected community sample of 22,194 working-aged adults. Information was collected on cold-induced finger blanching--including the extent and frequency of attacks in the past year, and on difficulty in using the upper limb in several everyday activities (e.g. doing up buttons, opening a tight screwtop jar, and pouring from a jug). Associations were examined by logistic regression with the resultant odds ratios converted into prevalence ratios (PRs) and 95% confidence intervals (95% CI).

RESULTS

Among 12,907 respondents were 1,359 who reported finger blanching and provided details of its extent and frequency. Of these, 7.4% reported frequent attacks (50 or more over the year), and 12% reported extensive blanching (affecting nine or ten digits). After adjustment for potential confounders, subjects with finger blanching reported an excess of difficulties in using the limb. Thus, in men with blanching the PR for difficulty with buttons was 4.7 (95% CI 3.9-5.8), and that for pouring from a jug was 3.8 (3.0-4.9) in comparison with men who had never had blanching. Similar associations were found in women and in those men with exposure to hand-transmitted vibration. The risk of reporting difficulties increased markedly with frequency of blanching--up to four- or fivefold in those with 50 or more attacks in the past year compared with those who had none; but differences by extent were less marked, with PRs < or = 1.6 in those with nine to ten digits affected compared with one to two digits.

CONCLUSIONS

RP and VWF are both associated with difficulties in using the upper limb in everyday tasks. Further investigation of potential reporting biases is warranted, but if the associations are causal, frequency of attacks influences impairment more than extent of disease. More account may need to be taken of frequency of blanching episodes in assessing and in compensating subjects with VWF.

Raynaud's phenomenon

Many persons are affected by the phenomenon known as Raynaud's. Raynaud's is classified in 2 ways-as Raynaud's disease or Raynaud's syndrome. Classification is based on the presence of associated conditions. Raynaud's is characterized by vasospasm-induced color changes of the fingers, toes, and ears. The fingers are most commonly affected. Studies involving cause, diagnosis, and treatment have been instituted with varied results. Diagnosis is primarily based on clinical symptoms involving digital color changes. Treatment is aimed at prevention of attacks and includes medication, stress reduction, and avoidance of vasoconstricting agents. Whether the phenomenon will develop into a more serious condition with which Raynaud's is associated is important. This article describes the etiology, pathophysiology, diagnosis, treatment, and nursing implications with regard to Raynaud's.

Criteria for the classification of early systemic sclerosis

We propose criteria for the early diagnosis and classification of systemic sclerosis that reflect the vascular and serological advances of the last 2 decades.

Raynaud's phenomenon

Raynaud's phenomenon is characterised by episodic vasospasm of the fingers and toes typically precipitated by exposure to cold. Mild Raynaud's is common and is not usually a harbinger of clinically important disability; its onset, however, can be startling and uncomfortable for patients, and the well recognised association in some cases with systemic rheumatic conditions often precipitates aggressive assessments for underlying diseases. Advances in vascular physiology have shed light on the role of the endothelium as well as endothelium-independent mechanisms in the altered vasoregulation of Raynaud's. We review clinical aspects of the disorder and new insights with respect to pathophysiology, and we discuss potential new therapeutics based on the disease mechanism, such as prostacyclin analogues, serotonin antagonists, and calcitonin gene-related peptides.

Digital vascular responses and serum endothelin-1 concentrations in primary and secondary Raynaud's phenomenon

OBJECTIVE

To determine circulating endothelin-1 levels (ET-1) in patients with primary or secondary associated Raynaud's phenomenon (RP) under resting conditions and in response to cold provocation.

METHODS

Patients were categorised as primary RP (18) or scleroderma associated RP (14). Finger blood flow was measured by venous occlusion plethysmography at finger temperatures of 32 degrees C and 24 degrees C. Vasospasm was detected as a finger systolic pressure of 0 mm Hg after standardised provocative cooling. Severity of vasospasm was assessed by the level of cooling required to provoke spasm. Plasma ET-1 levels were measured in antecubital blood withdrawn under baseline conditions (finger 32 degrees C) and at the point of vasospasm. Measurements were also made in 19 matched control subjects.

RESULTS

Finger blood flow was lower in patients with RP than in controls, with no difference between the two RP groups. Vasospasm occurred in all patients with RP but not in any control subjects and a grading system of severity was established. Baseline plasma ET-1 levels were similar in patients with RP and controls. Increases in ET-1 levels at the point of vasospasm in patients or corresponding timepoint in controls were also similar. There was no significant difference between the ET-1 levels in the two RP subgroups when the fingers were warm or when vasospasm was present.

CONCLUSIONS

These results do not support the hypothesis that ET-1 plays a part in the pathogenesis of RP. Objective testing is a useful adjunct to the clinical diagnosis of RP and allows assignment of a severity grade.

A two-stage, genome-wide screen for susceptibility loci in primary Raynaud's phenomenon

OBJECTIVE

To identify chromosomal regions containing genes involved in the susceptibility to primary Raynaud's phenomenon (RP).

METHODS

Six extended families with multiple individuals affected with primary RP (n = 37) were examined for linkage in a 2-stage, whole-genome screen, using a total of 298 microsatellite markers.

RESULTS

Multipoint, nonparametric linkage analysis identified 5 areas of possible linkage, with a nominal level of significance of P < or = 0.05. Analysis of a finer map of markers in these regions defined the regions of linkage as 21.4 cM on 6q13-6q23.3 (D6S261; P = 0.0004), 10.2 cM on 7p22-7p15 (D7S664; P = 0.014), 1.6 cM on 9p23-9p22 (D9S156; P = 0.0075), 5.1 cM on 17p13.1-17p12 (D17S1791; P = 0.036), and 11.8 cM on Xp11.4-Xp11.23 (DXS8054; P = 0.006). Three potential candidate genes map to these regions: the beta subunit of the muscle acetylcholine receptor and the serotonin 1B and 1E receptors.

CONCLUSION

These results provide evidence of the presence and location of genes that are involved in the genetic susceptibility to primary RP.

Pathophysiology and classification of the vibration white finger

Skin, arteries and nerves of the upper extremities can be affected by vibration exposure. Recent advances in skin and vascular biology as well as new investigative methods, have shown that neurovascular symptoms may be due to different vascular and neurological disorders which should be differentiated if proper management is to be evaluated. Three types of vascular disorder can be observed in the vibration white finger: digital organic microangiopathy, a digital vasospastic phenomenon and arterial thrombosis in the upper extremities. An imbalance between endothelin-1 and calcitonin-gene-related peptide is probably responsible for the vasospastic phenomenon. Moreover, paresthesiae can be due to either a diffuse vibration neuropathy or a carpal tunnel syndrome. A precise diagnosis is then necessary to adapt the treatment to individual cases. A classification describing the type and severity of the vascular lesions is presented. Asymptomatic lesions are included for adequate epidemiological studies and risk assessment of vibrating tools. Monitoring of vibration exposed workers should include not only a questionnaire about symptoms, but also a clinical evaluation including diagnostic tests for the screening of early asymptomatic neurovascular injuries.

Raynaud's phenomenon in older adults: diagnostic considerations and management

Raynaud's phenomenon (RP) is characterised by sensitivity to cold temperatures associated with either biphasic or uniphasic change in colour of the digits. Since few studies are available which include older adults, the prevalence of RP in the older adult population is estimated from surveys or studies of the general population. The causes of RP in older adults may differ significantly from those in young adults and, therefore, so would the evaluation of RP. Because of comorbitis that accompany advancing age, the management of RP in older adult patients must take into consideration toxicity and adverse reactions that may develop, especially in the frail individual. Although nonpharmacological therapy is preferable, slow-release calcium antagonists provide a relatively well tolerated and effective treatment for moderate to severe RP in older adult patients. Aggressive treatment including hospitalisation is appropriate for older adult patients during periods of critical digital ischaemia associated with RP.

Dynamic characteristics of laser-Doppler flux in normal individuals and patients with Raynaud's phenomenon before and after treatment with nifedipine under different thermal conditions

The study was aimed at choosing an appropriate characteristic of laser-Doppler flux (LDF) data for (1) distinguishing patients with Raynaud's disease from normal controls and (2) evaluating the effect of nifedipine under different thermal conditions. We checked the reliability of three characteristics of nonlinear dynamics as statistical dimension Ds, correlation dimension D2 and power-law index PLI. Their values depended heavily on the thermal condition. The most reliable characteristics that enabled us to distinguish the patients from normal controls and the effect of nifedipine under definite thermal condition proved to be Ds and PLI. The latter is simple for computation and is thus recommendable for clinical practice. Ds and PLI were higher in patients with Raynaud's compared to normal controls and diminished during the transitions from low to high temperature. However, the characteristics used were unable to distinguish significantly Raynaud's I from Raynaud's II patients.

[The circulatory status in the extremities in Raynaud's disease and syndrome]

In 39 patients with the disease and syndrome of Raynaud the state of the upper extremities blood circulation was studied up. The reliable lowering of indexes of the disease in III-IV stage in comparison with the normal level is noted. The most informative methods are rheoplethysmography and Doppler investigation of the main arteries of extremity.

Oral iloprost in Raynaud's phenomenon secondary to systemic sclerosis: a multicentre, placebo-controlled, dose-comparison study

OBJECTIVE

To identify the optimal dose of oral iloprost on the basis of efficacy and tolerability in patients with Raynaud's phenomenon secondary to systemic sclerosis.

DESIGN

Multicentre, randomized, parallel-group comparison of two different doses of oral iloprost and placebo.

SETTING

European university hospitals.

PATIENTS

A total of 103 patients with Raynaud's phenomenon secondary to systemic sclerosis.

INTERVENTION

Patients received one of three treatments for 6 weeks: placebo, oral iloprost 50 microg or oral iloprost 100 microg. Each treatment was taken twice daily, giving total daily doses of iloprost of 100 and 200 microg.

MEASUREMENTS

The frequency, total daily duration and severity of Raynaud's attacks were recorded in a specially designed patient diary; physician's global assessment and adverse events were recorded at visits to the clinic. Analysis was performed on an intention-to-treat population.

RESULTS

A total of 103 patients were recruited, 89 completed the assessments throughout the treatment period and 82 completed an additional 6 weeks of follow-up after treatment. Thirty-five patients received placebo, 33 received iloprost 50 microg and 35 received iloprost 100 microg. The mean percentage reductions in the frequency, total daily duration and severity of Raynaud's attacks were numerically greater in the iloprost groups at the end of treatment and at the end of follow-up. At the end of treatment (6 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.03), but not in the severity (P = 0.07) or the frequency of attacks (P = 0.37). At the end of follow-up (12 weeks), there were significant treatment differences in the total daily duration of attacks (P = 0.001) and in the severity of attacks (P = 0.007), but not in the frequency of attacks (P = 0.07). Percentages of patients improved at the end of treatment as assessed by the physician were 44% placebo, 57% iloprost 50 microg and 64% iloprost 100 microg (not significant). Side-effects were reported by 80% of patients on placebo, 85% on oral iloprost 50 microg and 97% on oral iloprost 100 microg. Premature discontinuations of treatment in each group were 9, 30 and 51%, respectively, with 6, 27 and 51% being due to adverse events.

CONCLUSION

The results on the daily duration of Raynaud's attacks suggest that both 50 and 100 microg oral iloprost twice daily may be effective in the treatment of Raynaud's phenomenon secondary to systemic sclerosis. The 50 microg iloprost dose was better tolerated in this patient group.

Clinical diagnosis found in patients with Raynaud's phenomenon: a multicentre study

A multicentre observational study was conducted in order to detect the major clinical diagnosis found in 761 patients with Raynaud's phenomenon (RP) attending 50 Italian centres for rheumatology and internal medicine. Systemic sclerosis was the most frequent condition associated with secondary RP, occurring in 216 (28.4%) patients. The other most frequent clinical diagnoses included systemic lupus erythematosus (52 cases: 6.8%) and rheumatoid arthritis (38 cases: 5%). Other RP-related diseases (hypertension, Sjögren's syndrome, mixed connective tissue disease, undifferentiated connective tissue disease, fibromyalgia, carpal tunnel syndrome, cryoglobulinemia, dermatopolymyositis, vasculitis, thoracic outlet syndrome, hypothyroidism, diabetes mellitus) occurred in less than 5% of cases. A total of 130 (48%) out of 268 patients with primary RP showed one or more clinical features indicating a fairly high risk of evolving into fully established systemic sclerosis. None of these patients fulfilled the ACR criteria for systemic sclerosis. This study shows that over 50% of patients with RP attending 50 Italian centres for rheumatology and internal medicine had a connective tissue disease. The large number of patients with primary RP and isolated clinical features of connective tissue disease indicates that more efforts should be focused on developing new criteria for the classification of RP.

Deficiencies of the Stockholm vascular grading scale for hand-arm vibration

OBJECTIVES

The internationally accepted Stockholm vascular grading scale for vibration white finger (VWF) has shortcomings that have received insufficient attention: some of its key descriptors require further definition and, more crucially, the scale does not suit all possible patterns of symptoms. To determine whether these shortcomings matter in practice, an attempt was made to apply the Stockholm vascular scale to 92 consecutive cases of VWF assessed by one area office of the Health and Safety Executive in the United Kingdom.

METHODS

Case definition was based on clinical history and examination, but blanching was confirmed from observations of 34 men (37% of the cases). The 145 affected hands were graded under 2 alternative definitions of "frequent attacks"; and the 92 persons were graded using the same definitions according to the extent of blanching in their worse affected hand.

RESULTS

Depending on the choice of definition of frequent attacks, between 36% and 61% of the affected hands fell outside the scale and were unclassifiable. Thirty percent of the individual cases could not be classified under either definition, and 28% altered their grading according to the definition. The findings were broadly similar when the analysis was restricted to the 34 cases with observed blanching.

CONCLUSION

It was concluded that the Stockholm vascular scale does not encompass the full range of disease and that its grading is highly sensitive to different interpretations of "frequent attacks". Alternative approaches to clinical grading are required.

Raynaud's phenomenon and systemic sclerosis

In systemic sclerosis, the exaggerated generalized vasospastic tendency is clinically represented by Raynaud's phenomenon as shown by an early digital arterial closure after cold stimulation, and by an inadequate vasodilatory response to heat. The phenomenon is not restricted to the extremities, and can also occur in internal organs. Repeated attacks of Raynaud's phenomenon may contribute to vascular disease in systemic sclerosis by a mechanism of reperfusion injury of the endothelium, and may contribute to tissue fibrosis. Although the aetiology and pathogenesis of Raynaud's phenomenon remain unknown, recent advances in the understanding of mechanisms of vascular tone control provide us with an opportunity to reconsider the pathogenetic process of Raynaud's phenomenon. It is now clear that neuropeptides, the vascular endothelium, and platelets are the three major contributors to the control of vascular tone. Our hypothesis suggests the presence of a sensory nervous system failure, leading to an unopposed endothelial and platelet control of vascular tone. Endothelial injury and platelet activation in systemic sclerosis lead to a shift in vascular function to a pro-vasospastic function not balanced by a vasodilatory sensory input; thus, enhanced vasospasm is generated. The investigation of the role of local vascular mediators in vasospasm may lead to a better understanding of vascular tone control and of Raynaud's phenomenon pathophysiology in systemic sclerosis.

Office evaluation and treatment of Raynaud's phenomenon

BACKGROUND

Raynaud's phenomenon, an episodic vascular disorder induced by cold temperatures or stress and characterized by white, blue, and red discoloration of the fingers and toes, may affect up to 20% of the general population.

KEY POINTS

Raynaud's phenomenon may exist independently (primary) or in association with an underlying disease (secondary), most commonly systemic sclerosis. The pathophysiologic features include vasospasm, endothelial cell changes, vessel obstructive features, and hemorrheologic factors. Raynaud's phenomenon is the initial manifestation of disease in 70% of patients with systemic sclerosis, in whom it may be present for many years before the development of the connective tissue disease. Patients with primary Raynaud's phenomenon need only conservative management and should be reassured that digital ischemia and loss of tissue occur extremely rarely. Pharmacologic agents that have been studied include vasodilators, platelet inhibitors, serotonin antagonists, and fibrinolytics.

CONCLUSIONS

For prognostic and therapeutic reasons, it is important to determine if Raynaud's phenomenon is associated with an underlying condition and if the patient may develop a connective tissue disease.

The relationship between subjective vasospastic complaints and finger blood flow measurements in Raynaud's phenomenon

BACKGROUND

Objective circulatory tests in patients with Raynaud's phenomenon have only rarely been related to subjective complaints.

METHODS

In 55 Raynaud patients the correlation between daily self-recorded frequency, duration and severity of vasospastic attacks and the measurement of finger skin blood flow during local cooling was investigated.

RESULTS

No significant correlations were found between complaints as registered in the diaries and finger skin temperature and laser Doppler flux before, during and after a standardized local cooling procedure.

CONCLUSION

Finger skin blood flow measurements do not necessarily reflect digital vasospasm in daily life. Besides studies on the diagnostic value and reproducibility of skin blood flow measurements in Raynaud's phenomenon, the relationship of test results to subjective complaints should be established.

Validity and reliability of three methods used in the diagnosis of Raynaud's phenomenon. The UK Scleroderma Study Group

Three different assessment methods for the classification of Raynaud's phenomenon (RP) were compared. These were (i) a previously validated method using colour charts supplemented with a short questionnaire, (ii) answers to a questionnaire based on criteria derived from the consensus opinion of a group of clinicians, and (iii) individual clinician's assessment using standard descriptions based upon the same consensus view. We report the results of a study involving six clinicians and 30 subjects investigating the level of repeatability between the three methods and also the reliability between the six clinicians. There did not exist any overall systematic bias between the six clinicians. Further, agreement between them, as assessed by the kappa statistic, ranged from moderate to good. However, there did exist systematic bias between the results from all three of the classification approaches with agreement between them ranging from only poor to moderate. We conclude that the previously validated colour chart assessment is too insensitive to detect RP. Further, a structured questionnaire based on perceived clinician's opinion could not reproduce clinicians' classification in practice. By contrast, supplying clinicians with standard descriptions did yield a reliable classification system for RP.

Prevalence of Raynaud's phenomenon in a healthy Spanish population

To determine the prevalence of Raynaud's phenomenon (RP) in Spain, we studied a working population of 988 men and 479 women. The overall prevalence of RP was 3.7%, with a 3.2% rate for men and 4.7% for women. There was a statistically significant association between Raynaud's phenomenon and a personal or familial history of perniosis, acrocyanosis or migraine among women. The age at onset was significantly lower in women. RP was classified as primary in 89% of the cases and as secondary in 11%. Examination by capillaroscopy revealed no significant differences between primary Raynaud cases and controls.

Raynaud's phenomenon: a proposal for classification

Major confusion exists with regard to the definition of patients with Raynaud's phenomenon; defining the patient and the phenomenon are reasonably straightforward, but variations in the definition of its primary and secondary forms have created a situation in which the same patient might be classified as primary by one group and secondary by another. The present essay is a proposal for the strict definition of Primary Raynaud's Phenomenon (PRP) formulated as a hypothesis amenable to experimental testing. This hypothesis is tested retrospectively on a group of 240 patients with Raynaud's phenomenon. The proposed criteria permit classification in 215 of 240 cases or 89%, leaving 25 patients difficult to classify at initial evaluation. Further testing of the hypothesis is encouraged.

Early detection of scleroderma spectrum disorders in patients with Raynaud's phenomenon

Fifty patients with the chief complaint of Raynaud's phenomenon (RP) presented at our scleroderma clinic from March to December 1990. Physical examination, routine laboratory tests (blood, urine and chest X-ray), determination of the pattern of RP, antinuclear antibody (ANA) tests and examination for nailfold bleeding were performed. Three patients were diagnosed as having systemic sclerosis sine scleroderma, 15 patients as having RP with positive anticentromere antibody and 6 patients as having an incomplete form of mixed connective tissue disease. Thus, a total of at least 24 patients out of 50 (48%) were shown to have a scleroderma spectrum disorder. A definite RP pattern (triphasic or biphasic and bilateral), positive ANA and positive nailfold bleeding were strongly correlated statistically, suggesting that these are simple useful findings for the early detection of scleroderma spectrum disorders in patients with RP. We expect that there are many undiagnosed patients with an early-stage scleroderma spectrum disorder in the general population.

Raynaud phenomenon: the Jepson classification

The Jepson classification of Raynaud phenomenon, based on its pathogenesis, is presented. Raynaud phenomenon can be induced in the fingers of the normal hand as the digital vessels are sensitive to the direct effects of cold. A 'local fault' in the digital arteries renders the fingers more susceptible to a fall of environmental temperature, as do limb artery occlusions which impair the digits' ability to maintain their temperature. Other vasoconstrictive influences act similarly to precipitate the onset of the phenomenon.

A new capillaroscopic assessment of microvascular damage vs Maricq classification in patients with isolated Raynaud phenomenon

A new classification for microvascular lesions assessment by means of capillaroscopy is proposed in this research. The new method, offering a numerical score for microvascular lesions, was used in patients affected by isolated Raynaud Phenomenon (RP). RP can often be associated with scleroderma and, therefore, the new classification has been compared to the Maricq one for what concerns this connective tissue disorder. The numerical method is as sensitive as that by Maricq, but, as easily expected, its specificity is quite low. It appeared to be satisfactory also the positive predictive value of the new capillaroscopy classification combination with the clinical examination and with the immunologic biohumoral investigation. It is particularly easy to apply this method, as it presents to the examinator a restricted range of answers, for the capillaroscopic picture description, but it needs further studies in different microcirculation damages to be proved definitely valuable.

[Raynaud's disease and syndrome. Presentation of clinical experience]

The Authors report their experience concerning 256 cases of Raynaud's Disease and Syndrome observed from 1968 to 1987; 23 patients underwent surgery for the treatment of dystrophic or gangrenous lesions of the extremities (12 cervico-thoracic and 8 lumbar sympathectomies, 1 popliteal aneurysmectomy, 2 scalenotomies): a significant improvement of the clinical picture was observed in 91.30% of the patients who underwent the operation. The pharmacologic treatment obtained satisfactory results in 51.26% of all the patients. The Authors propose a three stage classification of raynaudian symptoms: I stage: sporadic vasoconstrictive crises; II stage: recurrent vasoconstrictive crises not invalidating working activity and "restitutio ad integrum" between attacks; III stage: recurrent and frequent crises invalidating working activity with asphyxia and/or ulcer-gangrene of the extremities. Both pharmacological and surgical treatment obtained the improvement of the clinical condition to an inferior stage in a high rate of patients. In three patients only (two of whom underwent scalenotomy and one popliteal aneurysmectomy) the complete and definitive cessation of raynaudian crises was observed.

A review of 132 consecutive patients referred for assessment of vibration white finger

One hundred and thirty-two subjects were referred to the Institute of Occupational Health in Birmingham over a 2 year period for assessment as to whether they met the criteria for Prescribed Disease A11 (vibration white finger). A standardized questionnaire and checklist was used, and each patient with vibration white finger was staged according to the Taylor and Pelmear (1975) classification. One hundred and sixteen subjects (88 per cent) had a clinical picture consistent with a diagnosis of vibration white finger, of which 10 did not meet the DHSS criteria for prescription. For these 116 subjects, the mean age at initial occupational exposure to vibration was 27 years. The mean age when symptoms began was 40 years. Numbness was the most common symptom accompanying the periodic blanching. More claimants reported symptoms affecting their hobbies and social life than affecting their work. The main job activities that exposed these claimants to vibration were pedestal grinding, pneumatic chipping/grinding, and hand grinding. Different systems available for staging vibration white finger have inherent limitations, but a scheme that uses standardized objective tests will make the diagnosis and assessment less reliant on subjective symptoms alone.

[Laser Doppler flowmetry. Principles and clinical applications in vascular acro-syndromes]

Twenty-seven subjects with vasospastic diseases: 13 primary and 5 secondary Raynaud phenomenon (RP), 3 primary RP treated with raubasin 60 mg/day, 6 acrocyanosis and 9 normal subjects were studied in a standardized experimental set (thermostatic chamber), recording cutaneous digital micro-vascular reactions to cold and heat exposure by laser Doppler flowmetry, a relatively new method for the objective and reliable assessment of blood flow in the cutaneous microvasculature. The data suggest that patients with vasospastic disease have a defect in local microvascular flow regulation, that is revealed by low temperature exposure. The major difference between primary and secondary RF was recovery time (stop reaction) after cold test, that is easily recorded by this instrumental set. The morphology of the recording and the flow recovery time of acrocyanosis were found to be similar to those of secondary RF.