Clot Chronicles: Putting a Finger on Raynaud’s

Hi, I’m Dr. Marie Gerhard. I’m a vascular medicine doctor in the cardiovascular division of Brigham and Women’s Hospital, and we’re going to be talking about Raynaud’s phenomenon today. 

I think the issue for Raynaud’s phenomenon is, initially, just understanding what it is. Every patient now has access to a smartphone, which makes it easier for us because the diagnosis is made by looking at well-demarcated pallor/whiteness or cyanosis/blueness that affects the tips of the finger, the whole finger, or the toes or the tip of the nose. This picture shows you what that means. Demarcation – white to the regular skin color. 

So, the issue is that this can look quite horrific and is quite frightening to many people, particularly when their fingertips are turning blue. So, the questions are usually: are my fingers going to fall off, how do I make this stop, and why did this happen? For the first question, I think it’s very, very important to people to understand why this happened, and “are my fingers going to fall off?” Like right now, is this an emergency? 

The answer to that is see if you can make it go away by warming the fingers up. The simplest thing for the patient is just finding a warm spot, like under your armpits, putting your fingers in and seeing if the white or blue goes away. Some people run their fingers under hot water for a little bit; that can work. If it doesn’t go away and it stays there for a long time—we’re talking 1 hour or 2 hours, 3 hours—you need to get yourself to a physician to see if it’s actually not Raynaud’s, which would be white or blue that comes and goes, but instead some fixed problem to the fingers.

Now, the issue of “am I going to lose my fingers?” is tough. If this started when a person was in their teens—particularly common in women in their teens—it can be very disabling and can make it difficult to do things like go skiing or ice skating. Anything that you can do to increase your central warming (your core warming) and make it go away leads to primary Raynaud’s phenomenon. 

If you’ve had no problems your whole life and this is showing up in your late 20s or early 30s, then we start to worry there’s another reason this is happening. Those reasons are typically things that would affect the arteries to the fingers, the toes, the tip of the nose, and they respond to the cold stimuli by vasoconstricting and cutting off flow. Those are things as straightforward as thyroid disease, or collagen vascular disease/rheumatologic diseases. 

So, for those patients, it’s going to be all fingers/all toes being affected. The person will usually have a sign that they have that other disease process. For example, you can pick up clinical clues for thyroid disease. Collagen vascular disease is very scary for many people and ranges from lupus to scleroderma. For many of those diseases, we’ll also have clues. And you’re going to do a very careful exam looking for rashes, telangiectasias, or veins on the skin that are new and prominent joint problems. 

The worrisome one is scleroderma where this is a new and somewhat disabling problem and it’s hard to relieve those episodes of white or blue, and the fingers get fat. That is the case where the Raynaud’s phenomenon can actually precede the illness of scleroderma. So again, if they’re bad episodes, they’re hard to relieve, you need evaluation and someone to help you. And the reason for that is that we have medicine for all of these secondary causes; some that are very specific to the disease process, and some that are just specific to relieving the clamping down of blood vessels (vasoconstriction).

And if push comes to shove, we even have intravenous therapies and some local surgeries that help. Those are saved for the people that are really disabled where we really cannot relieve the white or blue episodes. At the end of the day, you need to know that there’s help. There’s lots of ways for us to help people and have them live their life with far fewer episodes of these white and blue fingers, toes, tips of nose, earlobe issues. And particularly with secondary Raynaud’s phenomenon, if we can actually get a handle on what the underlying cause is, we can do a lot to make them better. 

Now, this picture shows someone with all fingers. Generally, if it’s all fingers and all toes, we look for those systemic problems that I talked about, i.e., rheumatologic diseases, etc. But if it’s just one finger, we start to look at anatomic reasons, like they’re using a wood saw or a chainsaw, or other occupations such as pottery that can actually have an effect on specific (but not all) fingers. Again, with new prolonged episodes, that definitely merits an evaluation. We don’t want people to try to manage this disability on their own. If it’s really causing them discomfort, we can help. 

Thank you for joining me on Clot Chronicles.

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