Raynaud’s Phenomenon

Raynaud's phenomenon is a vascular condition characterized by a sudden decrease in blood flow (vasoconstriction) to the hands, feet, or other body parts, resulting in a series of color changes in the affected areas. These changes progress from white (pallor) to blue (cyanosis) and finally to red (erythema) as blood flow returns. Patients may experience severe pain, numbness, tingling, or a pins and needles sensation during these episodes. In more severe or chronic cases, tissue loss, ulceration, and gangrene can occur.

Raynaud's phenomenon is often triggered by exposure to cold temperatures, stress, or anxiety. The condition can be classified as primary or secondary. Primary Raynaud's (Raynaud's disease) typically develops in women under 30 and has no associated medical condition. Secondary Raynaud's is linked to underlying rheumatologic, autoimmune, or vascular diseases such as systemic lupus erythematosus (SLE), systemic sclerosis (SSc; scleroderma; CREST), Sjogren's syndrome, mixed connective tissue disease (MCTD), rheumatoid arthritis, or thromboangiitis obliterans (Buerger's disease). Secondary Raynaud's is often more severe and carries a higher risk of tissue loss, ulceration, or gangrene.

Initial evaluation and treatment for Raynaud's phenomenon are typically provided by a primary care physician or rheumatologist. Non-pharmacologic treatment options may include avoiding cold exposure and sudden temperature changes, managing stress and anxiety, and ceasing smoking or nicotine use. More severe cases may require medications such as calcium channel blockers (e.g., amlodipine, nifedipine), phosphodiesterase (PDE) inhibitors (e.g., sildenafil (Viagra), tadalafil (Cialis)), or nitroglycerin ointment.

Some individuals may continue to have painful episodes of Raynaud’s phenomenon or develop tissue loss that may threaten the viability of the fingers and risk amputation. In these individuals with severe and persistently symptomatic Raynaud’s phenomenon, referral to a surgeon with expertise in the treatment of Raynaud’s phenomenon may be warranted.

When referred to a surgeon for Raynaud's phenomenon, patients have likely been under the care of a primary care physician or rheumatologist. The surgeon will take a detailed history to understand the patient's symptoms and previous treatments. A thorough examination of the hands will assess blood flow to the fingers and evaluate any wounds at the fingertips. Handheld Doppler ultrasound may be used to listen to the blood flow in the fingers. As part of this evaluation, it is important to assess for and rule out other causes of ischemia (impaired blood flow) in the fingers, which may require different treatment. In some cases, an arteriogram may be necessary to map the blood vessels in the wrist and hand and identify any diseased or occluded (blocked) vessels requiring additional surgical intervention. The ultimate goal of this assessment is to evaluate for: 1) the severity of the Raynaud attacks and their effect on the individual’s quality of life, 2) tissue loss with associated ulceration and gangrene, 3) and any vascular (blood vessel) occlusions that may require reconstruction.

Depending on the severity of the condition, some patients may benefit from botulinum toxin (Botox) injections. While Botox is commonly associated with cosmetic procedures, it can also effectively treat Raynaud's phenomenon. When injected near blood vessels in the hand and wrist, Botox can improve blood flow, resulting in significant pain relief and, in many cases, promoting the healing of ulcerations. While some patients may require only a single injection, the effects of Botox wear off after several months, which may necessitate repeat injections. The advantage of this treatment over surgical options is minimal downtime and recovery.

In more severe cases or when blood vessel blockages require reconstruction, surgery may be recommended. Surgery for Raynaud's phenomenon aims to achieve three primary goals:

1) Reduce vasospasm (blood vessel constriction) responsible for Raynaud's attacks. Vasospasms are caused by the sympathetic nervous system. A sympathectomy procedure blocks this signal transmitted by the nerves. Surgeons perform microsurgery to strip away the tissue (adventitia) surrounding the small blood vessels of the wrist and hand, preventing the blood vessels from receiving the message to constrict. This procedure requires specialized operating room microscopes, meticulous technique, and experience.
2) Reconstruct any blood vessel blockages. These blockages are often identified through angiograms performed before surgery. Blocked blood vessels are typically reconstructed or bypassed using a vein graft, a segment of the vein taken from another part of the body such as the leg. Microvascular surgical techniques are used to restore blood flow to the hand and fingers with the vein graft.
3) Address tissue loss, ulceration, and gangrene. This often involves debriding the affected tissue by cutting away dead or unhealthy tissue, resulting in a clean and healthy wound bed more likely to heal.

Recovery time for patients treated with Botox injections is relatively short, with localized soreness lasting only a few days. This minor discomfort rarely interferes with regular activities, and there are typically no restrictions on activities following the injections.

For patients undergoing surgery, recovery often takes several weeks as the surgical sites heal. During this time, gentle hand motion is encouraged, but lifting and heavy activity are limited. With improved blood flow to the hand, pain often subsides quickly, and associated open wounds begin to heal.

Be sure to see an experienced surgeon to treat this condition. Our fellowship-trained specialists at The Buncke Clinic in San Francisco treat patients with Raynaud’s phenomenon from across the Bay Area and Northern California. Contact us to schedule a consultation.

Below are links for third party resources

American College of Rheumatology