🧵 Raynaud’s: Benign Chill or Scleroderma Warning?

Cold hands turn white/blue/red.
Sometimes it’s harmless.
Sometimes it’s systemic sclerosis knocking.
Here’s how to tell—fast. 👇
@Amansharmapgi @DurgaPrasannaM1 @IhabFathiSulima @DrAkhilX @CelestinoGutirr @SarahSchaferMD @NeuroSjogrens #MedTwitter #RheumX
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1) What counts as Raynaud’s?
Recurrent, cold- or stress-triggered color change in digits: white → blue → red (can be biphasic).
Tingling/pain on rewarming is common.
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2) Primary vs Secondary (the fork in the road)
Primary = young, mild, symmetric, no ulcers, normal exam.
Secondary = red flags below → think rheumatology disease.
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3) Red flags for Secondary Raynaud’s
•Onset >30 yrs or male
•Asymmetric attacks
•Digital ulcers, pitting scars, gangrene
•Puffy fingers, skin thickening, telangiectasias, calcinosis
•Abnormal nailfold capillaries (giant loops, hemorrhages, dropout)
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4) Drugs & factors that worsen it
Nicotine, caffeine surges, non-selective beta-blockers, ergotamines, amphetamines, decongestants, chemo (e.g., cisplatin), vibrating tools, cold exposure.
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5) Quick workup if red flags present
•Nailfold capillaroscopy (capillary abnormalities = secondary)
•ANA ± ENA (centromere, Scl-70, RNAP III)
•CBC, TSH; consider ESR/CRP, cryoglobulins if atypical
•Check for digital ischemia: pulses, Doppler if concerned
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6) Who to worry about most
Systemic sclerosis (limited/diffuse), MCTD, SLE, myositis, Sjögren’s, vasculitis, antiphospholipid syndrome; also large-vessel/occlusive disease.
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7) First-line management (everyone)
Warmth (gloves/hand warmers), avoid cold & vibration, stop smoking, stress control, avoid trigger meds, keep core warm, rapid re-warming routine.
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8) Pharmacologic (stepwise)
1.Dihydropyridine CCB (e.g., nifedipine/amlodipine)
2.Add/consider losartan or topical nitroglycerin
3.Refractory/ischemic: phosphodiesterase-5 inhibitor (e.g., sildenafil)
4.Severe ischemia: IV prostacyclin (iloprost/epoprostenol); ± sympathectomy in select cases
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9) Digital ischemia = emergency
Rest pain, non-healing ulcers, tissue loss, or critical pallor/cool digits → urgent hospital: vasodilators, analgesia, protect tissue, rheum + vascular input, consider heparin/prostacyclin.
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10) Look-alikes you shouldn’t confuse
•Acrocyanosis: persistent blue, painless, symmetric
•Pernio/chilblains: itchy violaceous plaques after cold
•Frostbite: true cold injury with blister/necrosis
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11) Pocket algorithm
Color change episodes → check red flags.
If none: lifestyle ± CCB.
If any: capillaroscopy + ANA/ENA, screen for systemic disease, escalate therapy, protect digits.
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📌 Takeaway
Most Raynaud’s is benign.
But ulcers, asymmetry, capillary changes, or skin clues = secondary until proven otherwise.
Spot it early. Save fingers—and sometimes lives.

If this makes Raynaud’s easier to manage on rounds, share it so fewer serious cases are missed. 🔁
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