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Raynaud's phenomenon - Management
What should I do to differentiate between primary and secondary Raynaud's phenomenon?

  • In the history and systemic enquiry:
    • Assess the frequency and severity of attacks.
    • Determine whether symptoms are asymmetrical (suggesting secondary) or symmetrical (suggesting primary or secondary).
    • Take an occupational history, drug history, and smoking history.
    • Ask about any family history of connective tissue disease.
    • Ask about symptoms of underlying disease (particularly connective tissue diseases), such as morning joint stiffness, swollen joints, rash, photosensitivity, hair loss, frequent oral or nasal ulcers, significant dry eyes or dry mouth, puffy hands, symptoms of significant oesophageal dysmotility or gastro-oesophageal reflux disease, severe muscle weakness, breathlessness, and weight loss.
  • In the examination:
    • Look for complications including digital ulcers, infection, or gangrene (which only occur in secondary Raynaud's phenomenon, and usually require immediate admission to hospital for treatment).
    • Look for synovitis, puffiness of fingers, tightness of the skin, and livedo reticularis (mottled, cyanotic discolouration that can be associated with connective tissue disease and peripheral vascular diseases).
    • Check blood pressure and peripheral pulses in both arms.
    • Inspect the nail folds for dilated capillaries. These look like red pen marks, and are most often seen at the cuticles. They are highly suggestive of underlying connective tissue disease.
      • This can be done using an otoscope, ophthalmoscope, or dermatoscope (using a drop of oil), if available, but may require experience. See photos on the Archives of Dermatology website.
      • If in doubt, refer to a rheumatologist for further evaluation.
  • For investigations:
    • Do a full blood count (FBC), erythrocyte sedimentation rate (ESR), and check for anti-nuclear antibodies.
    • Consider also checking or requesting, if clinically indicated, renal function, liver function tests, serum immunoglobulins and electrophoresis, urinalysis, and hand and chest radiography (although these investigations will be done in secondary care if referral is planned).

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