Vibration white finger

Vibration white finger syndrome also known as vibration-induced white finger, is sometimes considered a form of secondary Raynaud’s phenomenon or Raynaud’s phenomenon of occupational origin, is the vascular component of the hand–arm vibration syndrome ¹. The term ‘hand–arm vibration syndrome’, is used to describe vascular, neurological and other disorders associated with occupational exposures to hand-transmitted vibration ¹. Vibration white finger syndrome signs and symptoms include numbness, pain, and blanching (turning pale and ashen). Vibration syndrome has adverse circulatory and neural effects in the fingers. Of particular concern is evidence of advanced stages of vibration syndrome after exposures as short as one year. The National Institute for Occupational Safety and Health (NIOSH) recommends that jobs be redesigned to minimize the use of vibrating handtools and that powered handtools be redesigned to minimize vibration ². Where jobs cannot be redesigned to eliminate vibrating tools such as pneumatic hammers, gasoline chain saws, and other powered handtools, engineering controls, work practices, and administrative controls should be employed to minimize exposure.

Prolonged use of vibrating handheld tools results in the development of hand-arm vibration syndrome, a complex health hazard involving vascular, neural and musculoskeletal systems ³. Vibration-induced white finger, a secondary form of Raynaud’s phenomenon, is the typical clinical manifestation of vascular injuries in hand-arm vibration syndrome. Episodic blanching of the fingers is characteristic for vibration-induced white finger, which is commonly provoked by exposure to cold.

Raynaud’s phenomenon also known as Raynaud’s disease or Raynaud’s syndrome, there is vasoconstriction of the digital arteries and cutaneous arterioles causing some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress ⁴. In Raynaud’s disease, smaller arteries that supply blood to your skin narrow, limiting blood circulation to affected areas (vasospasm). In 1 to 3% of the cases, these blanching attacks become progressively more severe over the years, leading to blue and cold fingers; even though the skin may become atrophic, ulcerated, or gangrenous ².

Vibration white finger syndrome or “secondary Raynaud’s phenomenon” has the same signs and symptoms and progresses through the same stages of severity as primary Raynaud’s phenomenon but may be correlated with a specific cause (i.e., other medical conditions, vinyl chloride, or vibrating handtools). Some medical conditions, particularly fractures, lacerations, costoclavicular syndrome, connective tissue diseases, vascular disorders such as Buerger’s disease, generalized atherosclerosis, or a long history of high blood pressure, may result in the same signs and symptoms as primary Raynaud’s phenomenon.

Early stages of vibration white finger syndrome are characterized by tingling or numbness in the fingers. Temporary tingling or numbness during or soon after use of a vibrating handtool is not considered vibration syndrome ². To be diagnosed as vibration syndrome, these neurologic symptoms must be more persistent and occur without provocation by immediate exposure to vibration ². Other symptoms of vibration syndrome include blanching, pain, and flushing. The symptoms usually appear suddenly, and are precipitated by exposure to cold. With continuing exposure to vibration, the signs and symptoms become more severe and the pathology may become irreversible.

The severity of vibration syndrome can be measured using a grading system developed by Taylor ⁵. After a clinical observation and an interview, a worker can be placed into one of the categories in Table 1.

Table 1. Stages of vibration syndrome

Stage	Condition of Fingers	Work and Social Interference
00	No tingling, numbness, or blanching of fingers	No complaints
OT	Intermittent tingling	No interference with activities
ON	Intermittent numbness	“
TN	Intermittent tingling and numbness	“
01	Blanching of a fingertip with or without tingling and/or numbness	“
02	Blanching of one or more fingers beyond tips, usually during winter	Possible interference with nonwork activities; no interference at work
03	Extensive blanching of fingers; during summer and winter	Definite interference at work, at home, and with social activities; restriction of hobbies
04	Extensive blanching of most fingers; during summer and winter	Occupation usually changed because of severity of signs and symptoms

[Source ² ]

Millions of workers are occupationally exposed to handtransmitted vibration in the world, and the prevalence of vibration-induced white finger among them can be as high as 71%, depending on the type and duration of exposure to hand-arm vibration ⁶. In many industrialized countries, vibration-induced white finger is a common prescribed occupational disease. Among the workers using vibratory tools, the prevalence of vibration-induced white finger varies from 0–5% in tropical countries to 80–100% in workers exposed to high vibration magnitude in northern countries ⁷. In the industrialized countries, the costs of awarding compensation claims and disability benefits associated with vibration-induced white finger are very high ³. It is concluded that vibration-induced white finger is not a progressive condition following cessation of exposure to vibration. On the contrary it may be static or even reversible to some extent ⁸.

At present, to diagnose vibration-induced white finger or hand-arm vibration syndrome objectively, no gold standard test is available. Also, there is a growing controversy regarding the diagnostic ability of the widely used tests ⁹. Currently, for diagnosing vibration-induced white finger, a medical interview by a qualified physician including a positive history of finger blanching attacks in persons occupationally exposed to hand-transmitted vibration is the best method ¹⁰. But to diagnose vibration-induced white finger among workers, quantitative objective assessment is essential, which should also aid in grading its severity and assessing progression or regression over time.

Primary vs. secondary Raynaud’s phenomenon

There are two main types of Raynaud’s phenomenon.

1. Primary Raynaud’s also called Raynaud’s disease, this most common form isn’t the result of an associated medical condition. It can be so mild that many people with primary Raynaud’s don’t seek treatment. And it can resolve on its own.
2. Secondary Raynaud’s also called Raynaud’s phenomenon, this form is caused by an underlying problem. Although secondary Raynaud’s is less common than the primary form, it tends to be more serious.

Signs and symptoms of secondary Raynaud’s usually appear around age 40, later than they do for primary Raynaud’s disease.

Causes of secondary Raynaud’s phenomenon include:

• Connective tissue diseases. Most people who have a rare disease that leads to hardening and scarring of the skin (scleroderma) have Raynaud’s. Other diseases that increase the risk of Raynaud’s include lupus, rheumatoid arthritis and Sjogren’s syndrome.
• Diseases of the arteries. These include a buildup of plaques in blood vessels that feed the heart (atherosclerosis), a disorder in which the blood vessels of the hands and feet become inflamed (Buerger’s disease), and a type of high blood pressure that affects the arteries of the lungs (primary pulmonary hypertension).
• Carpal tunnel syndrome. This condition involves pressure on a major nerve to your hand, producing numbness and pain in the hand that can make the hand more susceptible to cold temperatures.
• Repetitive action or vibration. Typing, playing piano or doing similar movements for long periods and operating vibrating tools, such as jackhammers, can lead to overuse injuries.
• Smoking. Smoking constricts blood vessels.
• Injuries to the hands or feet. These include wrist fracture, surgery or frostbite.
• Certain medications. These include beta blockers, used to treat high blood pressure; migraine medications that contain ergotamine or sumatriptan; attention-deficit/hyperactivity disorder medications; certain chemotherapy agents; and drugs that cause blood vessels to narrow, such as some over-the-counter cold medications.

Secondary Raynaud phenomenon is associated with different etiologies. It is most commonly associated with connective tissue disorders such as scleroderma, systemic lupus erythematosus, Sjogren syndrome, and antiphospholipid syndrome ¹¹.

Drugs, such as antimigraine medications, interferon alpha and beta, cyclosporine, and nonselective beta blockers, can cause secondary Raynaud phenomenon.

Occupations that result in overt vibrational exposure from vibrating machinery mostly affect males. This is known as hand-arm vibration syndrome. Exposure to polyvinyl chloride, cold injury from work, or ammunition work are other occupational-associated causes of secondary Raynaud phenomenon.

In the population of patients older than 60 years, the obstructive vascular disease is a frequent cause of Raynaud phenomenon. Obstructive vascular disease causes include thromboangiitis obliterans, microemboli, diabetic angiopathy, or atherosclerosis.

Infections associated with secondary Raynaud phenomenon include parvovirus B19, cytomegalovirus, hepatitis B, and hepatitis C.

Other causes of secondary Raynaud phenomenon include fibromyalgia, polycythemia, arteriovenous fistula, myalgic encephalitis, or malignancy.

Risk factors for Raynaud’s phenomenon

Risk factors for primary Raynaud’s disease include:

• Sex. More women than men are affected.
• Age. Although anyone can develop the condition, primary Raynaud’s often begins between the ages of 15 and 30.
• Climate. The disorder is also more common in people who live in colder climates.
• Family history. A first-degree relative — a parent, sibling or child — having the disease appears to increase your risk of primary Raynaud’s.

Risk factors for secondary Raynaud’s phenomenon include:

• Associated diseases. These include conditions such as scleroderma and lupus.
• Certain occupations. These include jobs that cause repetitive trauma, such as operating tools that vibrate.
• Exposure to certain substances. This includes smoking, taking medications that affect the blood vessels and being exposed to certain chemicals, such as vinyl chloride.

Vibration white finger causes

The exact pathophysiological mechanisms for vascular injury in vibration syndrome or hand-arm vibration syndrome are not fully understood yet ¹². Among patients with vibration-induced white finger, hyperreactivity of the sympathetic nervous system is reflected by the presence of high digital vascular tone with lowered skin temperature and blood flow in fingers under cold environments ¹³. Among the local vasoregulatory components, increased endothelin-1 and plasma catecholamine release with increased α2-adrenoreceptor reactivity together with inadequate release of nitric oxide and calcitonin gene-related peptide lead to the dysregulation of vascular tone in favor of vasoconstriction ¹⁴. Moreover, several circulating intravascular factors have been implicated in the pathophysiology of vibration-induced vascular injury. These include increased plasma level of thrombomodulin and von Willebrand factor, enhanced erythrocyte aggregation and hypodeformability, platelet activation, increased levels of thromboxane A2 and intercellular adhesion molecules ¹⁴. All these may be followed by narrowing of the arterial lumen with medial smooth muscle hypertrophy and diminished digital microcirculatory blood flow ⁹.

White finger syndrome pathophysiology

Three mechanisms contribute to Raynaud phenomena. These are decreased blood flow, blood vessels constriction, neurogenic responses, and inflammatory and immune responses.

The somatosensory system helps with temperature perception based on environmental stimuli. Afferent nerve fibers stimulated by cold temperatures activate A-delta and unmyelinated C-fibers. This eventually leads to activation of cold receptor TRPM8 (transient receptor potential ion channel) which monitors variations in cold temperatures. Activation of TRPM8 results in cutaneous vasoconstriction, thermogenesis, and avoidance of cold.

With cold temperatures, the sympathetic nervous system causes the release of vasoconstricting neuropeptides and norepinephrine leading to vasoconstriction of arteriole smooth muscle and decreased blood flood to the skin. Of note, in secondary Raynaud phenomena, endothelin-1 is released by endothelial cells which causes vasoconstriction.

In primary Raynaud phenomenon, an increase in alpha-2 adrenergic sensitivity in the digital and cutaneous vessels results in the vasoconstrictive response to cold temperatures and emotional stress. Alpha-2 adrenergic receptors are present on the distal arterial smooth muscles of the digits and affected by the sympathetic nervous system. Studies demonstrated that the use of alpha-2 adrenergic receptor inhibitors in patients with cold-induced attacks decreased the severity of the attack.

In secondary Raynaud phenomenon, the underlying disease is the factor that disrupts normal vessel reactivity to cold temperatures. Usually, the endothelial function of the digital and cutaneous vessels is compromised leading to eventual vasoconstriction with resulting tissue ischemia. For instance, fibrosis of the vascular system in systemic scleroderma leads to endothelial dysfunction followed by tissue ischemia ¹⁵.

Vibration white finger prevention

The National Institute for Occupational Safety and Health (NIOSH) recommends that engineering controls, medical surveillance, work practices, and personal protective equipment be used to help reduce exposure to vibrating handtools and to help identify vibration syndrome in its early stages among workers likely to be at risk ².

Engineering controls

The amount of exposure to vibration in many jobs can be reduced by proper job and production design. Where job redesign is not feasible, direct intervention by means of reducing tool vibration should be attempted.

1. Recommendation 1: Production lines should be engineered to minimize the need to use vibrating handtools. For example, quality controls on casting could be increased to reduce the average refinishing needed.
2. Recommendation 2: Tool manufacturers should modify and redesign tools to reduce hand-arm vibration. Tools with reduced vibration levels should be furnished to workers. Purchasers are encouraged to request suppliers to provide evidence that their equipment reduces vibration. More research is needed before a specific standard can be recommended for vibrating handtools. In the meantime, purchasers are encouraged to select tools that minimize vibration. Such information can be obtained from manufacturers’ product or technical brochures.

Medical surveillance and worker education

The number of vibration syndrome cases reported is small. Physicians have failed to diagnose the syndrome and workers tend not to report it. All workers who use vibrating handtools are at risk and should be examined for signs and symptoms of vibration syndrome. An examination is recommended because the severity of vibration syndrome appears to be directly related to the cumulative duration of exposure and because health effects can become irreversible.

• Recommendation 3: More research is needed in order to specify an optimum surveillance program, but for the present, NIOSH recommends that a medical surveillance program be implemented and that it should be tailored to the degree that workers use vibrating handtools. It should include preplacement examination of all new workers and an initial examination of all present workers who use vibrating handtools. Work histories should be included in all examinations. Work histories should include any prior exposure to vibrating handtools. Medical records, including health and work histories, should be maintained throughout employment and for an extended period after termination of employment.
• Recommendation 4: Workers using vibrating handtools and their employers should be informed of the symptoms of vibration syndrome.
• Recommendation 5: Workers should see a physician promptly if they experience prolonged symptoms of tingling, numbness, or signs of blanched or blue fingers.
• Recommendation 6: Health professionals, particularly occupational health physicians, should be trained in the appropriate clinical examination and interview necessary to diagnose vibration syndrome ¹⁶.

Work practices

Some tools, such as grinders, can cause greater vibration levels to impinge on the hand when wear is uneven or their alignment slips. While insufficient information is available to recommend a safe exposure duration, it is known that the severity of vibration syndrome is related to the extent and duration of continuous exposure to vibration.

• Recommendation 7: Vibrating handtools should be carefully maintained according to manufacturers’ recommendations.
• Recommendation 8: Work schedules with a 10-minute break after each hour of continuous exposure may help reduce the severity of vibration syndrome. Research is needed to determine, however, whether another schedule of rest breaks on job rotation is more appropriate.
• Recommendation 9: Workers are advised to:
  1. Wear adequate clothing to keep the body temperature stable and normal, since a low body temperature reduces blood flow to the extremities and therefore may trigger an attack of vibration syndrome. Workers are also advised to keep hands warm and dry while on the job. When their hands become wet and chilled, workers should dry them and put on dry warm gloves before additional exposure to vibration. More than one pair of gloves may be required on the job.
  2. Let the tool do the work, grasping it as lightly as possible while working safely and maintaining tool control. The tool should rest on the workpiece or support as much as possible. The tighter the tool is held, the greater the vibration transmitted to the worker.
  3. Substitute a manual tool or other processes where practical.

Personal protective equipment

Many types of gloves help maintain body warmth, and, in addition, some designs may attenuate vibration; however, this may be limited to only some of the higher frequencies found in vibrating handtools. Although gloves alone are not recommended as a method of reducing vibration transferred to the hands, they will help keep hands warm, and thus help reduce the severity of vibration syndrome.

To help prevent Raynaud’s attacks:

• Bundle up outdoors. When it’s cold, don a hat, scarf, socks and boots, and two layers of mittens or gloves before you go outside. Wear a coat with snug cuffs to go around your mittens or gloves, to prevent cold air from reaching your hands.
• Use chemical hand warmers. Wear earmuffs and a face mask if the tip of your nose and your earlobes are sensitive to cold.
• Warm your car. Run your car heater for a few minutes before driving in cold weather.
• Take precautions indoors. Wear socks. When taking food out of the refrigerator or freezer, wear gloves, mittens or oven mitts. Some people find it helpful to wear mittens and socks to bed during winter. Because air conditioning can trigger attacks, set your air conditioner to a warmer temperature. Use insulated drinking glasses.

Vibration white finger symptoms

Raynaud’s phenomenon affects your blood circulation. When you’re cold, anxious or stressed, your fingers and toes may change color.

Signs and symptoms of Raynaud’s phenomenon include:

• Cold fingers or toes
• Color changes in your skin in response to cold or stress
  1. The skin turns white as blood flow is restricted.
  2. Sometimes the skin turns blue as blood vessels react.
  3. Then the skin turns red as blood flow returns.
  4. Another skin finding seen during a Raynaud phenomenon attack is livedo reticularis. This results in purplish mottling or reticular pattern over the skin due to small blood vessel clots. This finding is reversible with rewarming but is irreversible with secondary causes, such as antiphospholipid syndrome, vasculitis, cold agglutinin disease, or peripheral vascular disease.
• Numb, prickly feeling or stinging pain upon warming or stress relief

Other symptoms can include:

• Pain
• Numbness
• Pins and needles
• Difficulty moving the affected area

A Raynaud phenomenon attack starts out with a single digit and then spreads to other digits symmetrically on both hands. During an attack of Raynaud’s phenomenon, affected areas of your skin usually first turn white. Then, they often turn blue and feel cold and numb. The thumb is usually also affected in secondary Raynaud phenomenon.

As a result of vasoconstriction, pin and needles sensation, numbness or finger aches or pain are common complaints with Raynaud phenomenon attacks. If the Raynaud phenomenon attack is severe, typically with secondary Raynaud phenomenon, digital ulceration of the tips of fingers and toes may occur due to prolonged vasoconstriction with subsequent tissue ischemia. Eventual gangrene or loss of digits may occur in severe forms of Raynaud phenomenon attacks. In general, Raynaud phenomenon attacks are less severe in primary Raynaud phenomenon compared to secondary Raynaud phenomenon.

As you warm and circulation improves, the affected areas may turn red, throb, tingle or swell.

Although Raynaud’s phenomenon most commonly affects your fingers and toes, it can also affect other areas of your body, such as your nose, lips, ears and even nipples. After warming, it can take 15 minutes for normal blood flow to return to the area.

Vibration white finger complications

If secondary Raynaud’s phenomenon is severe — which is rare — diminished blood circulation to your fingers or toes could cause tissue damage.

A completely blocked artery can lead to sores (skin ulcers) or dead tissue (gangrene), both of which can be difficult to treat. Rarely, extreme untreated cases might require removing the affected part of your body (amputation).

Vibration white finger diagnosis

The diagnosis of vibration-induced white finger is currently heavily reliant on the reporting of relevant symptoms, such as cold-induced finger blanching and an appropriate history of exposure to hand-transmitted vibration. In obtaining the history of a patient with suspected Raynaud phenomenon, clinicians should address the age of onset, the location of affected areas, the presence of symmetry, the presence of digital ulcerations, and severity of the attacks. The presence of other systemic symptoms should be elicited to rule out secondary Raynaud phenomena. Provoking factors should be identified once confirmed to be Raynaud phenomenon. Provoking factors may include exposure to cold temperatures or sympathetic nervous system stimulation from emotional stress or being startled. Certain factors increase the likelihood for increased frequency of attacks, increased severity with worse pain. These include the presence of stress, female gender, low temperature, and the presence of a concurrent connective tissue disease. The later the onset of Raynaud phenomenon, particularly in the 30s and 40s age range, the higher the risk of the development of a connective tissue disorder.

The cold-induced blanching led to two alternative tests involving exposure to cold: the measurement of finger rewarming times after cold provocation ¹⁷ and the measurement of finger systolic blood pressures during cold provocation ¹⁸.

The time for finger skin temperature to rewarm after the hand and fingers have been cooled is a widely used test as an indicator of the abnormal response to cold observed in those with symptoms of vibration-induced white finger. Notwithstanding many investigations of the test ¹⁹, it is not possible to state its diagnostic power. There have been wide variations in the nature of the cold challenge (eg, duration and temperature of the cold challenge) and the diagnostic criteria used to identify an abnormality (eg, the extent of finger blanching). Some studies have suggested that the test may be useful for discriminating, on a group basis, between those with and those without vibration-induced vascular problems, but that it lacks the sensitivity and specificity to distinguish between individuals with and without vibration-induced white finger ²⁰. The diagnostic usefulness of a specific form of the rewarming test applied in the UK for medicolegal compensation claims has been questioned ²¹. This has encouraged the diagnosis of vibration-induced white finger from the reported symptoms, although this seems unsatisfactory when diagnoses determine whether workers lose their jobs or are awarded compensation. In air, finger skin temperature depends on the environmental conditions and blood flow through the digit ²², so the reliability of the test as an indicator of vibration-induced white finger can be expected to depend on many factors, especially the environmental conditions before, during and after the hands are immersed in water.

The measurement of finger systolic blood pressures after cold provocation is less commonly used than that of finger rewarming times, possibly because more complex equipment is needed for the test. During cold provocation of the fingers, the blood vessels constrict and finger systolic blood pressure falls ²³. The reduction is usually small in healthy persons but greater in fingers that are affected by the blanching associated with vibration-induced white finger ²⁴. The cold-induced reductions in finger systolic blood pressures seem to be related to reports of finger blanching and have been reported to have greater sensitivity and greater specificity than finger rewarming times ²⁵. It has been suggested that finger systolic blood pressures are more reproducible than finger rewarming times and that cold-induced reductions in finger systolic blood pressures are more useful indicators of vibration-induced white finger than finger rewarming times ²⁶.

Nailfold capillary microscopy is also utilized as a diagnostic method to differentiate primary Raynaud phenomena from secondary Raynaud phenomenon. It analyzes microvascular and morphologic changes in peripheral vessels seen with connective tissue disease, such as changes in architecture, capillary size, capillary density, the presence of hemorrhage, and avascular areas without capillary loops. This is done using a dermatoscope or ophthalmoscope. Nailfold videocapillaroscopy can also be used. Abnormal nail-fold microscopy is correlated with an increased likelihood of the development of connective tissue disease. The changes were seen are capillary loops appear enlarged or there is a loss of capillary loops. If there are mega-capillaries with a decreased capillary density, then these changes are indicative of scleroderma ²⁷.

Sorting out primary vs. secondary Raynaud’s

To distinguish between primary and secondary Raynaud’s, your doctor might perform a test called nail fold capillaroscopy. During the test, the doctor examines the skin at the base of your fingernail under a microscope or magnifier for deformities or enlargement of the tiny blood vessels (capillaries).

If your doctor suspects that another condition, such as an autoimmune or connective tissue disease, underlies Raynaud’s, he or she will likely order blood tests, such as:

• Antinuclear antibodies (ANA) test. A positive test for the presence of these antibodies — produced by your immune system — might indicate a stimulated immune system, common in people who have connective tissue diseases or other autoimmune disorders.
• Erythrocyte sedimentation rate (ESR). This test determines the rate at which red blood cells settle to the bottom of a tube. A faster than normal rate might signal an underlying inflammatory or autoimmune disease.

No one blood test can diagnose Raynaud’s. Your doctor might order other tests, such as those that rule out diseases of the arteries, to help pinpoint a condition that can be associated with Raynaud’s.

Vibration white finger treatment

Treatment of Raynaud phenomenon aims at decreasing the frequency and severity of the attacks with prevention of tissue ischemia.

Conservative medical management to prevent Raynaud phenomenon attacks is a lifestyle change. This includes avoiding exposure to cold, staying warm, avoiding stimulants, avoiding anxiety or emotional stress, and smoking cessation.

Lifestyle and home remedies

A variety of steps can decrease Raynaud’s attacks and help you feel better.

• Avoid smoke. Smoking or inhaling secondhand smoke causes skin temperature to drop by constricting blood vessels, which can lead to an attack.
• Exercise. Exercise can increase circulation, among other health benefits. If you have secondary Raynaud’s, talk to your doctor before exercising outdoors in the cold.
• Control stress. Learning to recognize and avoid stressful situations might help control the number of attacks.
• Avoid rapidly changing temperatures. Try not to move from a hot environment to an air-conditioned room. If possible, avoid frozen-food sections of grocery stores.

What to do during an attack

Warm your hands, feet or other affected areas. To gently warm your fingers and toes:

• Get indoors or to a warmer area
• Wiggle your fingers and toes
• Place hands under armpits
• Make wide circles (windmills) with your arms
• Run warm — not hot — water over your fingers and toes
• Massage your hands and feet

If stress triggers an attack, get out of the stressful situation and relax. Practice a stress-reduction technique that works for you, and warm your hands or feet in water to help lessen the attack.

Medications

If the patient fails to respond to only conservative therapy, then pharmacologic therapy with a vasodilating mechanism of action is used. Dihydropyridine calcium channel blockers are the first-line pharmacologic treatment for Raynaud phenomenon. Dihydropyridine calcium channel blockers include amlodipine and nifedipine. When starting calcium channel blockers, the medication is started at the lowest dose and gradually titrated every 4 weeks depending on the patient’s response. Monitoring blood pressure response is important, particularly if the patient has baseline blood pressures that are low.

1. Amlodipine dosage: Minimum 5 mg to maximum 20 mg daily
2. Nifedipine dosage: Minimum 30 mg to maximum 180 mg daily

The medication may be administered as either slow-release form, rapid or short-acting form, or long-acting form. Typically, the slow-release or long-acting forms of calcium channel blockers are used. An urgent situation prompts the use of a rapid, short-acting form of calcium channel blocker, which is used more frequently in patients with severe form of Raynaud phenomenon.

Adverse effects of dihydropyridine calcium channel blocker includes dose-related peripheral edema, palpitations, reflex tachycardia, dose-related dizziness, and headaches.

Contraindications to dihydropyridine calcium channel blocker are hypotension, peripheral edema, angina, myocardial infarction. It should also be avoided in patients with severe aortic stenosis, hypertrophic cardiomyopathy, and severe pulmonary hypertension.

Calcium channel blockers should be avoided in pregnancy unless digit ischemia is present.

If the patient fails to respond to dihydropyridine calcium channel blocker therapy, a phosphodiesterase (PDE) inhibitor. It can be added to the current calcium channel blocker therapy if partial treatment response is noted to the calcium channel blocker. If there is no treatment response to the calcium channel blocker, then the PDE inhibitor can be used as monotherapy. Sildenafil is started at a low dose, 20 mg daily, and then titrated depending on response over a period of 4 to 6 weeks with a maximum dose of 20 mg 3 times a day.

Alternative therapy to treatment failure using calcium channel blocker and PDE inhibitor is topical nitrates, such as nitroglycerin, which is a direct vasodilator. Typically, 2% nitroglycerin ointment is used and applied to affected Raynaud phenomenon areas. Topical nitrates are absorbed systemically and may result in adverse systemic effects, such as hypotension, dizziness, and headache.

Other options, if the patient does not respond to the above therapies, include the following: losartan, fluoxetine, and prazosin.

If tissue ischemia is present in the digits and symptoms are severe, then intravenous infusion of prostaglandin is used. Different intravenous prostaglandins include iloprost, epoprostenol, treprostinil, and alprostadil. Prostaglandin functions as a strong vasodilator and also prevents platelet cell aggregation.

Bosentan blocks endothelin-1 vasoconstrictive effect. This is used in recurrent digit ulceration in CTD, such as systemic sclerosis. Surgery to remove the particular sympathetic nerves that cause vasoconstriction, also known as sympathectomy, can be used in severe, refractory cases.

In the setting of secondary Raynaud phenomenon and history of ischemic ulceration, low dose aspirin 81 mg should be used daily. If there is aspirin intolerance or contraindication, clopidogrel, or dipyridamole can be used instead ²⁸.

Surgeries and medical procedures

For some cases of severe Raynaud’s phenomenon, procedures that might be treatment options include:

1. Nerve surgery. Sympathetic nerves in your hands and feet control the opening and narrowing of blood vessels in your skin. Cutting these nerves interrupts their exaggerated responses. Through small incisions in the affected hands or feet, a doctor strips these tiny nerves around the blood vessels. This surgery (sympathectomy), if successful, might reduce the frequency and duration of attacks.
2. Chemical injection. Doctors can inject chemicals such as local anesthetics or onabotulinumtoxin type A (Botox) to block sympathetic nerves in affected hands or feet. You might need to have the procedure repeated if symptoms return or persist.

Alternative medicine

Lifestyle changes and supplements that encourage better circulation might help you manage Raynaud’s phenomenon. However, the evidence of effectiveness is unclear and more study is needed. If you’re interested, talk to your doctor about:

• Fish oil. Taking fish oil supplements could help improve your tolerance to cold.
• Ginkgo. Ginkgo supplements could help decrease the number of Raynaud’s attacks.
• Acupuncture. This practice appears to improve blood flow, so it may be helpful in relieving Raynaud’s attacks.
• Biofeedback. Using your mind to control body temperature might help decrease the severity and frequency of attacks. Biofeedback includes guided imagery to increase the temperature of hands and feet, deep breathing, and other relaxation exercises. Your doctor may be able to suggest a therapist who can help you learn biofeedback techniques. There are books and DVDs on the subject.

Talk to your doctor before taking supplements. Your doctor can warn you if there are potential drug interactions or side effects of alternative treatments.

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