ESVM Guidelines – the Diagnosis and Management of Raynaud's Phenomenon

413

Review ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon

Writing group

Jill Belch1, Anita Carlizza2, Patrick H. Carpentier3, Joel Constans4, Faisel Khan1, and Jean-Claude Wautrecht5

1 University of Dundee School of Medicine, Dundee, United Kingdom 2 Azienda Ospedaliera S.Giovanni-Addolorata, Rome, Italy 3 Grenoble University Hospital, Grenoble, France 4 Hopital St Andre, Bordeaux, France 5 Cliniques universitaires de Bruxelles, Brussels, Belgium

ESVM board authors

Adriana Visona6, Christian Heiss7, Marianne Brodeman8, Zsolt Pécsvárady9, Karel Roztocil10, Mary-Paula Colgan11, Dragan Vasic12, Anders Gottsäter13, Beatrice Amann-Vesti14, Ali Chraim15, Pavel Poredoš16, Dan-Mircea Olinic17, Juraj Madaric18, and Sigrid Nikol19

6 Angiology Unit, Azienda ULSS 2, Marca Trevigiana, Treviso, Italy 7 Department of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany 8 Division of Angiology, Medical University, Graz, Austria 9 Head of 2nd Dept. of Internal Medicine, Vascular Center, Flor Ferenc Teaching Hospital, Kistarcsa, Hungary 10 Institute of Clinical and Experimental Medicine, Prague, Czech Republic 11 St. James’s Hospital and Trinity College, Dublin, Ireland 12 Clinical Centre of Serbia, Belgrade, Serbia 13 Department of Vascular Diseases, Skåne University Hospital, Sweden 14 Clinic for Angiology, University Hospital Zurich, Switzerland 15 Department of Vascular Surgery, Cedrus Vein and Vascular Clinic, Lviv Hospital, Lviv, Ukraine 16 University Medical Centre Ljubljana, Slovenia 17 Medical Clinic no. 1, Iuliu Hatieganu, University of Medicine and Pharmacy, Cluj-Napoca, Romania 18 National Institute of Heart and Vascular Diseases, Bratislava, Slovakia 19 Asklepios Klinik St. Georg, Klinische und Interventionelle Angiologie, Hamburg, Germany

Country authors

Ariane L. Herrick20, Muriel Sprynger21, Peter Klein-Weigel22, Franz Hafner23, Daniel Staub24, and Zan Zeman25

20 Centre for Musculoskeletal Research, University of Manchester, Manchester, United Kingdom 21 Cardiology-Vascular Medicine, Cardiology Department, University Hospital Liège, Liège, France 22 Helios Klinik Berlin-Buch, Klinik für Angiologie, Berlin, Germany 23 Division of Angiology, Medical University, Graz, Austria 24 Department of Angiology, University Hospital Basel, Switzerland 25 Department of Clinical Cardiology and Angiology, Hospital Bulovka, Prague, Czech Republic

Summary: Regarding the clinical diagnosis of Raynaud’s phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud’s phenomenon. This consensus document starts with a clariﬁ cation about the deﬁ nition and terminology of Raynaud’s phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment.

Keywords: Raynaud’s, systemic sclerosis, vasospasm, hand arm vibration

The European Society Most knowledge on this topic derives from epidemio- for Vascular Medicine (ESVM) logical surveys and observational studies; few randomized studies are available, almost all relating to drug treatment and thus these guidelines were developed as an expert This society aims to further develop the specialty of vas- consensus document to aid in the diagnosis and manage- cular medicine in Europe in order to improve the vascular ment of Raynaud’s phenomenon. This consensus docu- health of the population and the overall quality of life and ment starts with a clarifi cation about the defi nition and health status of vascular patients. ESVM engages in pro- terminology of Raynaud’s phenomenon and covers the motion of scientifi c exchanges, education, cooperative diff erential and aetiological diagnoses as well as the symp- research, and quality of care in the fi eld of arterial, ve- tomatic treatment. nous, lymphatic, and microvascular diseases. As part of the endeavour to improve the medical care of vascular patients, a series of guidelines, fi lling gaps in the literature, are being formulated. Each of the ESVM member Aims and goals country’s society endorses the guideline after review and comment. The European Society for Vascular Medicine is an excellent opportunity to bring together experts from The aim of this guideline is not to replace expert opinion 16 diff erent countries who regularly manage patients on individual cases but to give the general practitioner with Raynaud’s phenomenon, in order to propose a con- (GP) in primary care insight into the diff erent types of sensual approach to the practical problems encountered Raynaud’s, the mechanisms for diagnosis/diff erential di- by patients with Raynaud’s phenomenon and their at- agnosis, and early management. As patients with primary tending physicians. Raynaud’s may be managed in primary care/family practice, a guideline, which clarifi es these points, will allow appropriate referral to secondary care for the small but signifi cant, proportion of Raynaud’s patients who require The need for guidelines for this (see below for recommendations for referral). This guideline aims to help such staff make appropriate on- the diagnosis and management ward referrals where appropriate. It aims to inform GPs of Raynaud’s phenomenon about associated conditions in secondary Raynaud’s and alert the GP about early symptoms/signs/markers of secondary Raynaud’s to ensure appropriate referral to sec- Raynaud’s phenomenon (RP) is highly prevalent in the ondary care. general population (prevalence 3–21 % depending on the We hope also that the guideline will be useful for non- climate) [1]. The literature regarding its clinical diagnosis, specialist secondary care staff , who might be referred such associated conditions, investigations, and treatment is patients to general clinics. It should be noted that this substantial, and yet no international consensus has been guideline deals only with the management of Raynaud’s published regarding the medical management of patients and not with any disorder to which RP is secondary; e. g. presenting with this condition. For example, the use of connective tissue disorders (CTDs). syndrome, phenomenon, and disease appears arbitrary in We hope to inform about investigations in primary care terms of the nomenclature, systematic diagnostic investi- for the Raynaud’s itself and importantly, for exclusion/ gations proposed in the literature vary from nil to exten- confi rmation of secondary Raynaud’s. The issue of man- sive work-ups, and the therapeutic strategies also vary tre- agement in secondary care will be covered in the Raynaud’s mendously [2]. phenomenon guideline II.

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Methods of assessment and ble digital colour changes. Thus, Raynaud’s phenomenon strength of recommendations (RP) is the overarching term for the condition of digital vasospasm producing blanching. Further clarifi cation is needed regarding the terms The following provides a key to levels of evidence and “Raynaud disease” and “Raynaud syndrome”. These terms grades of recommendations that were used in this guide- were coined in order to diff erentiate the two main aetiologi- line (modifi ed from the two other European vascular socie- cal subsets of Raynaud’s phenomenon: Raynaud disease, ties for consistency i.e. European Society of Cardiology, where there is no associated or underlying disorder and (ESC) [3] and European Society of Vascular Surgery (ESVS). Raynaud syndrome, where there is. Unfortunately, both these denominations have drawbacks: • Raynaud disease is used as a synonym for primary RP. Levels of evidence However, it is a benign condition, aff ecting 3 to 21 % of the general population [1] and is not associated Level A: Data derived from many randomised controlled with any tissue loss or progression under normal cir- trials (RCTs) or from meta-analyses. cumstances; as clinicians, we would like to reassure Level B: Data derived from one RCT or from large non- those patients and avoid an unnecessary medicaliza- randomised clinical trials. tion. The use of the word “disease” is thus misleading Level C: Consensus from experts or data from small stud- and not helpful. ies, registries or retrospective studies. • When the Raynaud’s is associated with other disorders, it is indeed a syndrome, since it associates several signs and symptoms and may be related to many aeti- Grades of recommendation ologies. The usual classifi cation of RP as a vascular acrosyndrome is consistent with this view. Raynaud Note: The grade of recommendation relates to the strength syndrome (RS) may occur with many other conditions of the evidence. It is not a measure of the clinical impor- and takes on the prognosis from them rather than from tance of the recommendation. the RS itself. Grade I: Evidence that a treatment or procedure is benefi - cial, and eff ective. However, as there is no additional value in the use of these Grade II: Confl icting evidence and/or diff erences in opin- terms, we propose to avoid any other denomination but ion of experts regarding the benefi t/effi cacy of the treat- primary or secondary Raynaud’s phenomenon. Such con- ment/procedure. sistency of terminology is crucial, because of the need for Grade IIa: The weight of evidence or opinion is in fa- standardisation to allow epidemiology and therapeutic tri- vour of benefi t/effi cacy. als of defi ned populations. Grade IIb: Benefi t/effi cacy is less well established. Grade III: Evidence or agreement that the treatment is not benefi cial nor is it effi cacious, and in some cases may even be harmful. Epidemiology and symptoms

There is an initial blanching of the skin resulting from vasospasm, usually followed by cyanosis due to deoxy- Deﬁ nition and nomenclature genation of the static venous blood and lastly, by rubor as a consequence of reactive hyperaemia after return of In 1862, Maurice Raynaud described a phenomenon of fl ow, producing the classical ‘triphasic colour change’. transient and reversible attacks of colour changes trig- However, this classical triphasic colour change is not al- gered by cold exposure, associated with various condi- ways present (occurring in about one-third of primary RP tions leading to diff erent outcomes, which he ascribed to patients and two thirds of secondary RP associated with an ischaemic mechanism [4]. However, even from the be- systemic sclerosis [5]) but blanching must be a feature in ginning the nomenclature used was not standardized. order for the diagnosis of RP to be made. As cyanosis and The title of his thesis “De l’asphyxie locale et de la gan- rubor are not always present, it should be remembered grène symétrique des extrémités”, and the focus on the that blanching alone can also allow for the diagnosis of trophic changes in its fi rst English shortened translation RP to be made. led to many workers naming conditions such as digital gangrene, digital ischaemia and digital ulcerations after Maurice Raynaud. Over the last twenty years, however, Recommendation 1: clarifi cation has been progressively observed in the litera- Raynaud’s phenomenon is the correct term for this ture, restricting the use of the the name ‘Raynaud’ to its disorder. It may take the form of primary Raynaud’s initial clinical description of cold induced ischaemic at- phenomenon or secondary Raynaud’s phenomenon. tacks of the extremities, manifested by transient reversi-

416 J. Belch et al., ESVM guidelines – Raynaud’s phenomenon

The colour changes start at the tip of the fi nger and Other vascular acrosyndromes/ spread to one, two or three phalanges, or more fi ngers. differential diagnoses • The demarcation of the colour changes is usually clear- cut and involves both volar and dorsal aspects i.e. it is Vascular acrosyndromes defi ne any condition either pri- circumferential. mary or secondary, vasospastic or obstructive, that induc- • There is almost always associated transient numbness es disturbances in the cutaneous microcirculatory network of the aff ected fi nger tips, often with paraesthesia on re- of the extremities. They include RP, acrocyanosis, livedo, warming. and erythromelalgia. Diff erential diagnosis has also to be • Vasospasm may be systemic, aff ecting other extremities made with related conditions including chilblains, cold in- e. g. nose, ears, tongue, and may be associated with other juries and paroxysmal digital haematoma. vasospastic disorders such a migraine, irritable bowel, • Primary acrocyanosis is a benign condition often and microvascular chest pain [6]. found in young women with low body mass index, often with anorexia, which associates painless distal symmetrical cyanosis of the upper limbs or all four extremities, Primary Raynaud’s phenomenon (PRP) with coldness and sometimes palmar or palmo-plantar hyperhidrosis due to sympathetic overdrive. The degree Classically PRP presents as symmetrical vasospasm, usually aff ecting both hands, brought on by a number of stim- uli including cold and emotion, but also carrying objects. Table I. The conditions which may be associated with secondary RP. The thumbs are often spared. It tends to begin at a younger Connective tissue disorders age than secondary RP. Trophic changes are not seen in – Systemic sclerosis (SSc) primary RP. If trophic changes are seen, the search for an – Systemic lupus erythematosus underlying condition must be thorough. – Mixed CTD PRP is nine times more common in women than men – Sjögren’s syndrome – Dermatomyositis/polymyositis and has an overall prevalence of 10 %, although it may af- – Primary biliary cirrhosis (often with underlying SSc) fect as many as 20–30 % of women in the younger age groups [2]. The proportion aff ected within a population de- Occupational – Hand arm vibration syndrome and hypothenar hammer syndrome pends on the local climate [1]. In addition to digital vessel – Vinyl chloride monomer exposure involvement, patients with RP may experience symptoms – Silica and solvents (causing systemic sclerosis) in the tongue, ear lobes, tip of the nose, and the nipples, and there is a high incidence of migraine in these patients. Drugs – Anti-migraine drugs e. g. ergot derivatives By far the largest group of patients presenting to their pri- – Non-selective β blockers, including eye drops mary care physician are those with primary RP, which typi- – Some cytotoxic drugs cally occurs in young women in their teens and twenties, – Cyclosporin (though may be obstructive especially in transplant with a familial predisposition; they account for the vast patients) – Bromocriptine majority of all cases of RP. – Interferon α and β – Cocaine or amphetamine abuse, cannabis – Estrogen replacement therapy without progesterone Secondary Raynaud’s phenomenon (SRP) – Ephedrine e. g. in ear nose and throat preparations Endocrine In contrast, more than 50 % of the patients with RP re- – Hypothyroidism ferred to secondary or tertiary care will have an associated – Pheochromocytoma underlying systemic disease. Trophic changes are seen in Paraneoplastic (e. g. carcinoid) secondary RP, particularly in RP associated with CTDs. There may also be symptoms of the associated disorder at Miscellaneous – Buerger’s disease (thromboangiitis obliterans) the time of presentation. – Low body mass index The predictors for the RP attack rate, severity, and – Following bariatric surgery pain are low average daily temperature, stress, anxiety, – Complex regional pain syndrome older age, and female gender. Recent studies have shown – Frostbite sequelae – Digital injury sequelae that the RP may predate systemic illness by up to two decades. The occurrence of certain clinical features may suggest a greater likelihood of disease progression to CTD (Table I). For instance, sclerodactyly (puff y fi n- Recommendation 2 gers with skin tightening) and pitting scars over the fi n- The terms primary Raynaud’s phenomenon and sec- ger pulp are associated with later development of other ondary Raynaud’s phenomenon should be used and features of CTD and may allow fulfi lment of the 2013 the terms ‘syndrome’ and ‘disease’ discarded. ACR-EULAR classifi cation criteria for systemic sclero- Grade IIa – Level C sis [7].

J. Belch et al., ESVM guidelines – Raynaud’s phenomenon 417

of cyanosis worsens in winter and during cold exposure reactive hyperaemia. This latter occurs most commonly and decreases in summer, but there is no attack, no de- in association with risk factors for atherosclerosis; and marcation, and no numbness [8]. However, this benign b) in myeloproliferative syndromes. These symptoms condition can be associated with a genuine primary RP, are more often improved by aspirin and sometimes re- most often a white only RP, due to the common ther- ferred to as erythromelalgia. moregulatio-related risk factors they share. The lack of • Paroxysmal digital haematoma (synonyms: Achen- fat insulation augments the normal vasoconstrictive re- bach syndrome, orange ecchymotique, digital venous sponse to cold in the digital vessels. apoplexy, spontaneous digital haematoma, haemor- • Livedo is a relatively common physical fi nding consist- rhagic phlebodystonia). It presents with a sudden acute ing of a red to blue mottled netlike discoloration of the pain in a fi nger, rarely in the palm or a toe. The onset is skin of the lower (more frequent) and upper limbs, po- spontaneous or after a minor mechanical stimulus. A tentially of the whole body. The literature is often con- painful tension persists for hours and an ecchymosis ap- fusing because diff erent synonyms are reported such as pears in the aff ected area. The concomitant oedema livedo reticularis (complete rings), livedo racemosa (in- may impair movements of the fi nger. The second, third, complete rings), purpura retiform (incomplete rings and and fourth fi ngers are commonly aff ected. Symptoms subcutaneous local necrosis), cutis marmorata, reticular and signs fade spontaneously over a few days. Very rare- cyanosis, and livedo annularis. Livedo is secondary to ly, a digital venous thrombosis may complicate the clini- organic or functional disorders of the eff erent dermo- cal picture. Pathogenesis can be ascribed to spasm and hypodermal arterioles that will induce deoxygenation in rupture of a venule. The syndrome mostly aff ects wom- the superfi cial venous plexus. Possible causes include: en in the fourth to sixth decades. Frequently, another vasospasm caused by cold (primary/idiopathic livedo), vascular primary acrosyndrome coexists [12] (acrocya- arterial embolism, increased blood viscosity, Sneddon’s nosis, chilblains, primary RP). syndrome, some drugs including phenylbutazone, and • Non-freezing cold injuries (NFCI) occur when tissue vasculitis (secondary livedo) [9]. The idiopathic form fl uids do not freeze (usually at about – 0.5° C), but local aff ects especially young women and is benign. Only the temperatures remain low for several hours or days. NFCI primary/idiopathic form fades when lifting or warming are probably often unreported and under-diagnosed. limbs. A complete work-up is needed when a secondary There is often a history of having been cold and wet for a form is suspected. sustained period and having been unable to dry out fully. • Chilblains (Pernio) often occur in patients with acrocya- On rewarming, the aff ected limb shows a localised sen- nosis, as oedematous papules of deeper hue in the ex- sory neuropathy. There are generally few other objective tremities, such as the fi nger or toe pads, but also the nail clinical signs. In severe cases, there is cold sensitisation folds, and the skin of dorsum of the feet and hand at the so that individuals are unable to work outside developing level of the small digital joints. They are pruriginous and oedema, hyperhidrosis and/or chronic pain resembling can be painful. Their location on the fi nger pads could be algoneurodystrophy [13]. confused with a permanent area of digital ischaemia as- • Frostbite is true tissue freezing caused by heat loss sociated with a secondary RP rather than with a benign suffi cient to cause ice crystal formations in superfi cial RP, but the pain is much milder and the itch pronounced. or deep tissues: There is evidence of the role of throm- They are more frequent in association with RP. They boxanes and prostaglandins in the tissue damage [13]. consist of infl ammatory cutaneous lesions in patients ex- The spectrum of injury varies from minimal tissue loss posed to non-freezing weather (and damp conditions) with mild long term sequelae to major necrosis of the during late winter or early spring. The lesions typically distal limbs with subsequent major amputations and present as painful erythematous or purple lesions with phantom limb pain. associated swelling or itching (sometimes with cutaneous necrosis, ulceration or blistering) of the fi ngers or toes (or both): They are frequently misdiagnosed as vasculitis or embolic events. Chilblains are a self-limiting Associated conditions in SRP process that usually resolves within 1 to 3 weeks [10]. • Erythromelalgia (= Erythermalgia) (EM) is a symptom The early diagnosis is important as RP is often the pre- complex characterised by: 1) burning pain in the ex- senting feature of CTD and therefore provides an op- tremities, 2) pain worsened by warming, 3) pain relieved portunity for early diagnosis. Early management might by cooling, 4) erythema of aff ected skin, and 5) in- prevent morbidity and might save lives. Introduction of creased temperature of aff ected skin [11]. The symp- organ screening early in associated diseases has been toms and fi ndings are most often intermittent and may shown to be associated with reduced disease progres- not present during physical examination. Two forms ex- sion and better outcomes [14]. Most cases of severe RP ist: Primary and secondary. Primary is a true primary are associated with CTDs. RP occurs in 90 % of patients vasodilatory disorder, secondary EM may be related to with systemic sclerosis (SSc) and is often perceived to two broad causes: a) Vasospastic in origin, where the be their most pressing clinical problem. It also occurs in blanching is absent and the burning erythema is due to a the other CTDs: in 85 % of patients with mixed CTD, in

418 J. Belch et al., ESVM guidelines – Raynaud’s phenomenon between 10 % and 45 % of patients with systemic lupus Table II. Conditions that may worsen existing Raynaud’s. erythematosus, in 33 % of patients with Sjögren’s syn- Anatomical drome, and in 20 % of those with dermatomyositis/poly- – Thoracic outlet syndrome myositis. Patients with rheumatoid arthritis have a simi- – Carpal tunnel syndrome lar overall prevalence of RP as compared with the general Drugs population (10 %); however, symptomatology tends to be As for Table I more severe. Atherosclerosis Patients presenting for the fi rst time in their third to fi fth decade are at high risk of developing CTDs. In RP occur- Cigarette smoking ring in very young children, an underlying CTD should be considered, especially if the symptoms include blanching and are severe. In patients with the limited cutaneous sub- Table III. Conditions where microvascular occlusion may mimic type of SSc, RP commonly precedes the diagnosis of CTD Raynaud’s and should be excluded. by several years, conversely rapid appearance of skin Occlusive vascular disease changes around the same time as the onset of RP is sugges- – Embolism (e. g. from thoracic outlet syndrome) tive of diff use cutaneous SSc. Systemic enquiry should Haematological concentrate on the presence of migraine (or a family his- – Malignancies tory of migraine), and the presence of a family history of – Cryo diseases (cryoglobulinaemia, cryoﬁ brinogenaemia and cold Raynaud’s (usually markers of primary RP) and musculo- agglutinin disease) – Hyperviscosity syndromes skeletal symptoms associated with CTD. A full physical examination should be directed to look Infection for any obstructive vascular disease and for signs of asso- – Hepatitis associated vasculitis ciated autoimmune conditions. Simple blood pressure measurement in both arms will help to detect signifi cant occlusive vascular disease above the brachial artery. Live- • A large subgroup of these listed conditions (such as do reticularis could point to cold agglutinin disease or un- some drug-induced necrosis, cancer and haematologi- derlying CTD. Patients with abnormal nail fold microsco- cal disorders associated with thrombosis or vasculitis of py are more likely to progress to a CTD (see below). any cause, or even frostbite) are digital necrosis, often Various drugs can precipitate or exacerbate RP. Of these, due to small vessel occlusion, not RP, their presence in B-blockers are the most frequently prescribed culprits. The the list being remnants of the nosological confusion ex- newer generation of vasodilating B-blockers, however, plained above. It should be noted that cold injury, how- seem to be safer in RP suff erers. In the older age group, ob- ever, can result in RP in the damaged area afterwards structive vascular disease is the most common cause of RP and this includes frostbite. Rarely, a true RP can be as- and it has been reported that 60 % of RP occurring in indi- sociated with these conditions, but only as sequelae of viduals older than 60 years is atherosclerotic in origin. In previous ischaemic trophic changes, and in the exact lo- workers exposed to vibration, hand-hammer syndrome cation of these trophic changes. They do not need to be must be considered. Hand arm vibration syndrome (HAVS), considered in patients with isolated RP and with no his- previously known as vibration white fi nger syndrome is the tory of such changes. most common form of occupational RP with a prevalence of • Any condition increasing vasoconstriction can worsen a 50 % in all workers using vibrating tools for any signifi cant pre-existing RP (vasoconstrictive drugs, hypothyroid- period of time. ism and pheochromocytoma). In these cases, as in other Other conditions associated with RP are listed in Table I. instances, there is an underlying true RP aetiology, Table II list conditions which might worsen already an es- which is worsened by the additional disease or drug. tablished tendency for RP, and Table III is where microvas- And sometimes several associated factors can be found cular obstruction mimics RP. in the same patient (e. g. a patient with hypothyroidism Again it is important to note that research is needed to and carpal tunnel syndrome, and an underlying limited clarify progressively what is associated with SRP and to be systemic sclerosis). Indeed, a multifactorial RP is not sure that some PRP are true PRP. For example, bariatric uncommon and the detection of one factor should not surgery, in the opinion of some experts, could be associat- conclude the aetiological evaluation. ed with the development of RP because of an important • RP was once thought to be a rare condition. However, its loss of weight and thermoregulation dysfunction. Howev- real prevalence is quite substantial in the general popu- er, no study has been done to assess this association. lation, yet some conditions often associated with RP are Moreover, it is possible that some RP considered as PRP not but still more prevalent in RP subjects than in the could be SRP, if future studies confi rm the possible role of general population. This has been shown at least for car- cryofi brinogenaemia [15]. pal tunnel syndrome and for thoracic outlet syndrome. However, it should be noted that there are a large num- However, the pattern of the attacks is often infl uenced ber of historically ‘associated conditions’ but they often by the associated condition (asymmetrical RP predomi- have diff erent aetiologies: nant in the medial nerve territory for carpal tunnel syn-

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drome, in C8-D1 territory for the thoracic outlet syn- ing of the skin elsewhere, especially around the mouth, drome). As they do not infl uence the prevalence from an malar rash, synovitis, and patchy alopecia. epidemiological point of view, these factors cannot be • Blood pressure should be checked in both arms where considered true aetiologies, but only worsening factors there is asymmetrical RP. and again, their detection in RP patients should not con- • Allen’s test is mandatory for the detection of distal arte- clude the aetiological evaluation. rial disease of the upper limbs. The hand is elevated and the patient is asked to clench their fi st for about 30 sec- onds. Pressure is applied over the ulnar and the radial Diagnosis in primary care arteries so as to occlude both of them. The occlusion is released one artery at a time. If colour returns quickly as History taking in the patient with RP described above, the Allen’s test is considered to dem- • A history of Raynaud’s symptoms will diagnose RP if onstrate normal circulation. If the pallor persists for there is a clear history of well demarcated blanching some time after the patient opens their fi ngers, this sug- (+/– cyanosis/rubor). Ask age of patient at onset of RP, gests a degree of occlusion of the uncompressed artery about frequency of attacks, whether associated with numbness, paraesthesia on rewarming or pain. Asking patients to photograph their fi ngers during an attack can Recommended primary care tests often help secure the diagnosis. As PRP is an augmenta- in the patient with RP tion of the vascular response to temperature, such patients may also have ‘excessive’ vasodilatory responses • Blood tests: Where there is any suspicion at all of a sec- to warmth, alcohol, and spicy food aff ecting not only the ondary RP, some basic blood tests can be helpful. Anti- fi ngers but face and chest wall. nuclear antibody (ANA) titres, should be measured [16]. • Taking a clear history will help to diagnose CTD or other If the ANA screen is positive, an ENA may be helpful. associated causes. Important symptoms to elucidate are The ENA screen may turn up anti-topisomerase antibod- photosensitivity, mouth ulcers, tightening of the skin, and ies associated with diff use systemic sclerosis, anti-cen- dryness of eyes or mouth. Drug history should be taken, tromere antibody with limited systemic sclerosis, anti Ro as should occupational history to look for hand arm vibra- or La with Sjögrens, and a positive anti DNA titre is sug- tion syndrome. In PRP a family history is often present. gestive of SLE. A full blood count will exclude many dis- • A history of migraine, irritable bowel, anorexia i.e. sys- orders, thyroid function should be checked. A CRP will temic vasospasm symptoms elsewhere is more likely to detect infl ammation (note: a normal CRP does not ex- be PRP. clude CTD). Plasma viscosity or ESR will also measure infl ammation. Unless symptoms or signs direct other- wise, this is usually a suffi cient primary care screen. Examination of the patient with RP • Urine: A Dipslide urinalysis can be useful in picking up renal involvement in conditions such as SLE. • On examination, check for colour change, but note that • Capillary microscopy: Abnormalities of the nailfold ves- the time the patient has been in the warm waiting room sels as detected by capillaroscopy is one of the most sen- may have attenuated an attack (thus the usefulness of a sitive ways to detect early CTD [17]. However, this is not photograph), and rubor alone may be witnessed as the usually performed in primary care, although a number of hands rewarm. Check the peripheral pulses to exclude clinicians do use dermatoscopy for skin lesions such as obstructive vascular disease. diff erentiating mole from melanoma and this can be • Look for signs of poor tissue nutrition such as trophic used to visualise the nail fold vessels. Though, low power changes in the nails, digital pitting, hacks or ulcers. Chil- (x 10) can miss early changes. An early referral to a sec- blains can co-exist in PRP. Digital ulcers are not seen in ondary care physician practising capillaroscopy is rec- PRP and are a strong pointer to SRP. ommended. Capillaroscopy plus more selective immu- • Look for signs of an associated disorder. Key signs in- nopathology tests can help the secondary care physician clude widespread telangiectasia, sclerodactyly, tighten- to exclude or confi rm CTD rapidly in most cases [18].

Recommendation 3 Recommendation 4 Conditions associated with RP should be divided into A thorough history and examination should be taken true associated disorders with aetiological links, those from all patients presenting in primary care to ensure which worsen RP or precipitate its appearance, and correct diagnosis of any underlying condition, as early those which do not cause vasospasm but digital diagnosis and organ screening in CTD improves necrosis. outcome. Grade IIb – Level C Grade IIa – Level C

420 J. Belch et al., ESVM guidelines – Raynaud’s phenomenon

• Other tests: Secondary care may carry out additional handling frozen food should be adopted. Simple sugges- tests, predominantly blood tests for underlying diseases tions such as keeping the trunk warm and providing occu- but also vascular tests such as plethysmography, cold pational therapy aids such as key holders to use when the challenge, etc. However, these are neither possible, nor fi ngers are numb can all help. Education is important and desirable for all patients in primary care and are there- an occupational therapist can provide useful advice, as fore not covered in this guideline. can patient self-help groups. It is essential that patients with RP stop smoking and, where applicable, avoid vibration exposure. Initial treatment in mild disease is conserv- Referral to secondary care ative and drug treatment reserved for those patients who do not respond to these conservative measures. Electri- • The majority of patients seen in primary care will have cally heated gloves and socks and chemical hand warmers PRP; however, missing early CTD or other associated are helpful in some patients. causes can have serious consequences, as organ in- In the case of HAVS, early diagnosis and early discon- volvement in CTD can be asymptomatic until exten- tinuation of vibration exposure may resolve the problem. sively progressed. Withdrawal of vasoconstrictor drugs should be consid- • Any symptom, sign or blood test that raises suspicion of ered when possible. Although the contraceptive pill has an SRP should prompt the physician to refer to second- been linked anecdotally to the development of Raynaud’s ary care. phenomenon, this has never been conclusively proven. In • RP associated with vibration requires referral to a vascular clinician with expertise in this area or an occupational physician. Recommendation 5 • Referral is recommended, if there is any suspicion of an All patients presenting with RP should undergo blood SRP, if any isolated signs of SRP are detected (such as tests including full blood count, ESR or CRP, and ANA digital ulcer), the patient has an abnormal ESR/CRP/ testing, and capillaroscopy when available. blood count, and an abnormal ANA and ENA screen. Grade IIa – Level C However, RP can be the precursor of CTD by many years and any worsening symptoms should trigger a referral. • Recommendation of referral to secondary or tertiary Recommendation 6 care should also be considered, if the RP is severely Capillaroscopy should only be carried out using equip- symptomatic and unresponsive to standard treatments. ment of good optical quality and by an experienced • Consideration should be given to secondary referral of operator, usually in secondary or tertiary care. children under the age of 12, as PRP may be less com- Grade IIa – Level C mon in the younger age groups. A high index of suspicion should be applied.

Recommendation 7 Capillary microscopy is a useful diagnostic tool. Ab- Management of RP normal capillary patterns are strong predictors of CTD and should be employed by secondary care. Not all patients experiencing digital vasospasm require Grade IIa – Level B drug treatment, but potential prescribers should be aware that the severity of the pain produced by vasospastic at- Recommendation 8 tacks and the degree of interruption that patients may ex- Children under the age of 12 should be referred to sec- perience in their normal daily routine can be profound. ondary care as PRP is less common in these age The aim of therapy is to provide symptom relief and im- groups prove quality of life. Management of RP depends on sever- Grade IIa – Level C ity, for example management of a patient with mild primary RP will be very diff erent from that of a patient with severe RP secondary to systemic sclerosis that has pro- Recommendation 9 gressed to digital ulceration. Patients with RP should be referred to secondary care when

General measures • there is evidence of an associated disorder or of oc- including lifestyle changes clusive vascular disease, • symptoms are severe or progressing despite ﬁ rst Education and avoidance of triggers are key. It is impor- line lifestyle and drug treatment tant to advise patients about protecting themselves from Grade IIa – Level C the cold. Lifestyle measures such as wearing gloves when

J. Belch et al., ESVM guidelines – Raynaud’s phenomenon 421 the management of digital ulceration in patients with severe RP, it is essential to treat any digital infection aggres- Recommendation 10 sively and quickly. Lifestyle change is an effective means of controlling RP attacks and should include dressing warmly, ceas- ing smoking, avoiding triggers such as cold, and an oc- Drug treatment cupational therapy assessment for aids if diffi culties are reported. Patients whose symptoms interfere with either their social Grade IIa – Level C or working lives and who have not responded adequately to ‘general’ measures, should be considered for drug therapy. Recommendation 11 Calcium channel blockers are the recommended fi rst Calcium channel blockers: Calcium channel blockers, line drug treatment for RP, if lifestyle modifi cation for example nifedipine, are the fi rst line drug treatment for alone has failed. RP. A meta-analysis of RCTs showed that nifedipine re- Grade I – Level A duced both the number and severity of RP attacks [19]. A recent Cochrane review of calcium channel blockers in primary PRP [20], which included 296 patients in seven clini- Recommendation 12 cal trials, found that calcium channel blockers were only Nifedipine in slow release form should be used to mini- minimally eff ective, with 1.72 (95 % confi dence intervals mise debilitating vasodilatory side effects and short du- 0.60 to 2.84) fewer RP attacks per week on calcium chan- ration of action. Care should be taken to increase dos- nel blockers compared to placebo. However, this was in age by increments to avoid side effects. If side effects the context of small same sizes, and ‘variable data quality’. are not severe, patients should be encouraged to toler- Many clinicians prefer long acting/delayed release prepa- ate them for two to three weeks as they may subside. rations, as the short-acting preparations are more likely to Grade IIa – Level C produce vasodilatory adverse eff ects and their action lasts only a few hours. The recommended dosage for nifedipine retard ranges from 10 to 20 mg two or three times a day. Starting at a low dose, minimises side-eff ects, however, be benefi cial in patients intolerant to other therapies which the 10 mg preparation is not available in all European are more likely to cause vasodilatory side eff ects. countries. Better tolerance of side eff ects can be obtained Newer vasodilatory drugs are being studied but evidence by introducing the drug slowly e. g. 10 mg at night for two is not yet available to support their use in primary RP. These weeks, then in the morning for two weeks then twice daily include phosphodiesterase-5 inhibitors (sildenafi l, tadala- etc. Adverse eff ects may disappear after a few weeks of fi l, vardenafi l) [25] and phosphodiesterase-3 inhibitors such treatment and patients should be encouraged to remain on as cilostazol. However, phosphodiesterase-5 inhibitors are therapy unless the vasodilatory side eff ects are intolerable. being increasingly used in systemic sclerosis-related RP, If adverse eff ects force discontinuation of nifedipine re- with a number of recent trials [26–29] and a meta-analysis tard, then other calcium channel blockers can be used [21]. [25] suggesting benefi t, although the trials were all of short These include amlodipine, lercanidipine or diltiazem. It duration and large, long duration controlled trials are re- should be noted that nifedipine retard has not been passed quired. Topical nitrates have recently been revisited. A mul- for use in children < 18 years of age or in pregnancy. ticentre, placebo-controlled trial (which included patients with both primary RP and secondary RP, most of whom had Other vasodilators: Treatment with other vasodilators re- systemic sclerosis) demonstrated benefi t from a novel for- mains controversial, as most studies have been uncontrolled mulation of glyceryl trinitrate (GTN), MQX-503, in terms of or contain very few patients. A Cochrane review of vasodila- improvement in Raynaud’s Condition Score. MQX-503 gel tors other than calcium channel blockers for primary RP was applied to the fi ngers immediately before or within fi ve [22] highlighted the lack of evidence base to support the use minutes of onset of a Raynaud’s attack over a four-week of any of other vasodilators, and calcium channel blockade period, and was applied for its local (as opposed to its sys- is the main pillar of treatment in primary care. Nonetheless, temic) eff ect [30]. if a patient does not respond to a calcium channel blocker, because of either ineffi cacy or intolerance, then it seems Prostaglandins: Prostaglandins (PGs) have potent vaso- reasonable to try another vasodilator [23]. Some clinicians dilatory and antiplatelet properties. Intravenous treatment favour the angiotensin receptor antagonist losartan, which with PGI2, its analogues such as iloprost [31], and PGE1 showed benefi t in a head to head open label trial against [32] have been shown to be benefi cial; however, intrave- nifedipine; however, no further studies have yet been pub- nous administration is a drawback. Oral PGs have been lished. Fluoxetine [24], an SSRl, was compared to nifedipine shown to be ineff ective in their current form [34]. A recent in an open-label cross-over study including patients with multicentre study of oral treprostinil in patients with sys- both primary and secondary RP and conferred benefi t in temic sclerosis-related digital ulcers [35] showed a small terms of frequency and severity of attacks. Fluoxetine may but statistically insignifi cant reduction in net ulcer burden

422 J. Belch et al., ESVM guidelines – Raynaud’s phenomenon compared to placebo after 20 weeks treatment. A meta- References analysis [36] and RCTs have shown benefi t with IV iloprost and treatment with PGs is recommended if nifedipine 1. Maricq HR, Carpentier PH, Weinrich MC, et al. Geographic vari- fails. However, these treatments must be performed in ation in the prevalence of Raynaud’s phenomenon: a 5 region comparison. J Rheumatol 1997; 24: 879–89. secondary care due to the need for IV infusion and moni- 2. Baines C, Kumar P, Belch JJF. Raynaud’s Phenomenon: toring of vasodilatory side eff ects such as hypotension, Connective Tissue Disorders: Systemic Sclerosis. In Rheuma- and so tend to be reserved for patients with severe RP sec- tology. MC Hochberg, AJ Silman, JS Smolen, Weinblatt ME, ondary to connective tissue diseases, often with digital ul- Weisman MH (Eds). Rheumatology 6th Edn. Elsevier Limited. 2013. ceration. Compared to nifedipine PGs are as eff ective at 3. European Society of Cardiology. Recommendations for Guide- symptom resolution, and better at ulcer healing. lines Production. A Document for Task Force Members. Inter- net: (Accessed 12th June 2016) https://www.escardio.org/ Other medical therapies [37]: Endothelin-1 receptor an- static_file/Escardio/Guidelines/ESC%20Guidelines%20 for%20Guidelines%20Update%202010.pdf. tagonists also have been investigated. Bosentan has been 4. Raynaud M. On local asphyxia and symmetrical gangrene of evaluated as a treatment of digital ulceration secondary to the extremities, 1864. London: The New Sydenham Society; SSc and conferred benefi t in two multicentre RCTs [38, 39] 1888. in terms of prevention of new ulcers, although it had no ef- 5. Maverakis E, Patel F, Kronenberg DG, et al. International consensus criteria for the diagnosis of Raynaud’s phenomenon. J fect on healing of existing ulcers. However its use for pure Autoimmun 2014;48-49: 60–5. 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