Raynaud's phenomenon

In Raynaud's the small arteries of the fingers and toes over-react: they narrow too readily, and for a short while the blood supply is cut off. Cold sets it off, and so does emotional stress; why the vessels react like this is not fully understood.

In most people Raynaud's is primary: nothing else is wrong, and the Raynaud's is the whole story. The teens or twenties are when it often first shows; women get it more than men, and it sometimes runs in families.

Systemic sclerosis, lupus and the other connective tissue diseases can each bring Raynaud's with them; that is the secondary form, and it is the less common one. Some medicines can bring it on, and so can heavy use of vibrating tools.

An episode follows a sequence of colour changes. Features include:

• In the cold, or under stress, fingers or toes turning white, then blue, then red; on brown or black skin the fingertips may simply look paler
• While it lasts, numbness, tingling or pain in the fingers or toes affected
• Pain as the blood comes back, then easing once the area is warm

In most people there is nothing behind the Raynaud's at all. A specialist review is still worthwhile in four situations: a start later in life, after about thirty; severe or one-sided symptoms; damage to the skin; and other symptoms alongside, such as joint pain, rashes or difficulty swallowing, since these can occasionally be pointers to an underlying autoimmune condition. The last two are for prompt medical advice rather than the next routine slot, as the section on when to seek help says.

Your history, an examination and blood tests for particular antibodies make up the assessment, and between them they help to sort the many with nothing behind it from the uncommon cases that need more attention.

Most people need nothing more elaborate than warmth, with the hands and feet guarded against the cold, and that is often very effective. When warmth alone leaves the symptoms troublesome, a medicine that opens up the blood flow can help. A calcium-channel blocker such as nifedipine is the usual first choice, and it is one that is talked over with you before you start: headache, flushing and ankle swelling are among its possible side effects, which is why the dose is raised gradually to a level you tolerate well, and it is avoided in the first half of pregnancy and while breastfeeding, so say if either applies. Some people need it every day, others only through the cold months. Should an underlying condition come to light, that condition gets treatment of its own. None of this is fixed in advance; it is adjusted to you.

Warming the hands is only half of it: the circulation answers to your core temperature, so the whole body needs to be kept warm. Habits that help:

• Several layers, plus gloves, warm socks and a hat, before you set foot outside
• Keep hand or pocket warmers with you, and at the first sign of an attack get indoors and warm the hands gently, never with anything hot enough to scald
• Less caffeine, and no smoking: caffeine can set off an attack, and smoking narrows the blood vessels and works against the medicines that open them
• Keeping active and keeping stress in check, since learning to manage stress can cut the number of attacks

For the primary type the outlook is good: in most people the symptoms hold steady or ease with time. Use any medicine you have been prescribed as agreed. A new sore, ulcer or broken skin on a finger or toe is for medical advice promptly, as the next section says, and the same day if it is getting more painful, red or discharging; other new things can wait for your review, unless the next section names them.

Once you warm up, an ordinary episode passes, usually within twenty minutes or so, and does no harm. Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111, or from your rheumatology team if you have one:

• A finger or toe that turns very painful, cold, dusky or numb and does not recover on warming, since the blood supply may be critically low
• A sore or ulcer on a finger or toe that is getting more painful, red or discharging, since an infection there can reach the deeper tissue and the bone, and needs treating without delay

If a sore like this comes with a high fever and shaking, confusion, rapid breathing, skin, lips or tongue turning blue, grey, pale or blotchy other than in the colour change of a Raynaud's attack (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), or feeling dramatically worse over hours, that is a 999 or A&E emergency, since the infection may have led to sepsis; call 999 and do not drive yourself to A&E.

Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken is a 999 or A&E emergency, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine, nifedipine among them, though fingers or toes that change colour in the cold, as they do in Raynaud's, are not what is meant; call 999 and do not drive yourself to A&E.

Any of the following can be a sign of poor blood supply or of an underlying condition, and is a reason to get medical advice promptly, from your GP, or your rheumatology team if you have one:

• A new sore or ulcer on a finger or toe, or one that is not healing, or skin there that has cracked or broken
• Other symptoms, new ones, arriving with the colour changes: joint pain, rashes, dryness of the eyes or mouth, or trouble swallowing, for instance

A routine specialist review, rather than urgent care, is where symptoms that are simply new or simply a nuisance belong. If you cannot tell how urgent something is, asking is never a mistake.

Raynaud's is usually harmless, and for the uncomplicated kind a specialist review is chiefly a source of reassurance; its other job is to find the small number of people in whom Raynaud's signals something that needs attention. Have yours checked if it has begun after the age of about thirty, if it is severe, or if other symptoms have come with it. Damage to the skin, or other symptoms alongside, should be raised sooner, as the section on when to seek help says.

How is Raynaud's diagnosed?

Your own account of the colour changes in the fingers or toes does most of the work, with an examination to back it up. Working out whether it is the harmless type or a sign of an autoimmune condition takes more: a specialist weighs your history, may send blood for tests of particular antibodies, and may look closely at the tiny vessels at the base of the nails, which can be telling; a photograph of your fingers during an attack helps too. All of this can often be completed in one visit.

Should I be worried about Raynaud's?

Usually not: for most people it is harmless, with nothing else behind it. It deserves a check when it begins after the age of about thirty, is severe or one-sided, damages the skin, or arrives with symptoms such as joint pain, rashes or difficulty swallowing: in that small group it can point to an autoimmune condition, and that is the main reason a specialist review can put your mind at rest; skin damage or new symptoms alongside are for prompt advice from your GP, or your rheumatology team if you have one, rather than a routine slot, as the section on when to seek help says.

Is there a cure, or will it fade on its own?

There is no cure to speak of, but the symptoms are very manageable, and for many people simple steps are enough to improve them a good deal. The foundation is warmth: the body as a whole kept warm and the hands and feet kept from the cold, which is often very effective. A medicine that opens up the blood flow can help if warmth is not enough, and when the Raynaud's belongs to an underlying condition, the treatment turns to that condition.

Will I need tablets, or an operation?

For most people, neither: warmth and the avoidance of sudden cold keep the symptoms under control. If the episodes go on troubling you regardless, a medicine can be introduced, a calcium-channel blocker for instance, its dose raised step by step to a level you tolerate well. Surgery, an operation on the nerves that control the finger vessels, is kept for severe cases that medicines have not helped. How far treatment goes depends on how much the symptoms affect you.