Treating Raynaud phenomenon: Beyond staying warm

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FIGURE 1
(A) White digits with intense vasoconstriction in Raynaud phenomenon; (B) blue digits with hypoxemic venous stasis; (C) red digits with hyperemic reperfusion.
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FIGURE 2
(A) Dilated nailfold capillaries in a patient with scleroderma (blue arrow); (B) dilation and dropout of nail-fold capillaries (white arrow) viewed with a magnifier.
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FIGURE 3
Our approach to diagnosis of Raynaud phenomenon and differentiating primary from secondary Raynaud phenomenon.

TABLE 1

Stepwise therapy for Raynaud phenomenon

Step 1	Cold avoidance
Step 1	Emotional regulation
Step 2	Dihydropyridine calcium channel blocker in maximum tolerated dose
Step 2	Phosphodiesterase type 5 (PDE5) inhibitor substituted for or added to a calcium channel blocker
Step 3	Topical nitrate (contraindicated in a patient already taking a PDE5 inhibitor due to risk of hypotension)
	Prazosin
	Fluoxetine
	Pentoxifylline
	Atorvastatin
For acute digital crisis	Calcium channel blocker plus topical nitrate or calcium channel blocker plus PDE5 inhibitor
	Intravenous prostacyclin
	Localized digital sympathectomy