We often see patients in the office complaining of painful, cold hands and feet during the winter months. A condition that could be overlooked is Raynaud's Phenomenon.

Remember to consider this differential diagnosis when performing the appropriate studies, which I will discuss below.

Raynauds is a condition caused by decreased blood flow to the tips of the toes and fingers. It could also reduce blood flow to our noses and ears. When Raynauds occurs on its own, this is known as primary.

When it happens with other medical conditions, such as autoimmune or connective tissue diseases, it is known as secondary. Some autoimmune and conductive tissue disorders include Lupus, Scleroderma, Crest Syndrome, Buerger disease, Sjogren syndrome, Rheumatoid Arthritis, Atherosclerosis, Thyroid, or Blood Disorders.

Patients usually complain that their feet feel very cold and tingly. They say they're getting discolored and turning white, blue, and red. Clinically, their skin feels cold, especially at the tips of their fingers or toes.
Often, doctors want to rule out peripheral vascular disease or acute arterial blockages, which can result in an arterial duplex.

A few other studies would help diagnose Raynaud's phenomenon. Common tests include a cold immersion/stimulation test and a cold pressor test:

• The cold immersion/stimulation study evaluates how well blood flows to the fingers and arteries. A small device measures the finger temperature. The fingers are then immersed in ice water for 20 seconds. The finger temperature is recorded every five minutes for 20 minutes until the study returns to normal. If it takes longer than 20 minutes for the temperature to return to normal after the ice water bath, it most likely means you have the Raynaud Phenomenon.

• The cold pressor test measures heart rate and blood pressure changes after immersing either hand or foot in ice water for one to three minutes. The cold stimulus activates sensory pathways that trigger a sympathetic response, which increases blood pressure. The test could also measure pain, thresholds, and tolerance.
  

Causes of Raynauds are usually triggered by prolonged exposure to cold temperatures. It could also be due to emotional stress.

Raynauds can be associated with autoimmune diseases like Lupus, Scleroderma, and Rheumatoid Arthritis.
If the patient's symptoms are severe or above the age of 35, doctors will want to rule out secondary Raynauds, which autoimmune or connective tissue disorders could cause.

Other tests to check for secondary Raynauds include nail fold capillaroscopy. The physician places oil at the base of a nail and examines it under a microscope. If abnormal arteries are present, it could indicate scleroderma or another connective tissue disease.

Blood tests also would be recommended to check for Lupus and Rheumatoid Arthritis; these labs would include an ANA, RA factor ESR, and CRP.

• Treatment includes keeping the fingers and toes warm, avoiding extreme cold temperatures, and wearing warm gloves and socks. 
• If patients will be out in extreme cold temperatures for a lengthy period, they could use hand and foot warmers. There are battery-operated or chemically operated hand and foot warmers. Exercise helps stimulate blood flow, which could be beneficial. If the patient is a smoker, it would help to talk to them about quitting smoking since nicotine is a vasoconstrictor. Avoiding or cutting down on caffeine and alcohol would also greatly benefit.
• It is rare, but complications could occur, which could lead to open sores on the toes and, left untreated, could lead to death of the tissue, which could lead to infection and Gangrene.

If the condition is related to secondary Raynaud's Phenomenon, I recommend discussing it with the patient's family physician or a vascular doctor. The patient may need to be prescribed medication to help dilate the blood vessels.

So, during these cold winter months, remember to put Raynauds in your differential diagnosis and work-up plan.

Jan Golden, DPM is a podiatrist practicing in The Northeastern part of PA in Moosic, Pennsylvania where she operates her own practice treating patients of the foot and ankle condition. Dr. Golden is Past President of PPMA.