History and examination

Raynaud's phenomenon is diagnosed clinically and requires that a number of points be covered during the history and examination:

In the history:

• classical triphasic changes in the colour of the extremities, inquire about
• the frequency and pattern of colour changes and at which stage(s) they experience
  • not all of the three phases are needed to make a diagnosis
  • an attack may last for minutes to hours.
• which digits are affected
• associated features such as pain and changes in sensation
  • patients may complain of tightness in the first two stages and burning pain in the reperfusion stage.
• what triggers an attack e.g. - drug exposure (beta-blockers, oral contraceptives), use of vibrating machinery, work in cold environment (fishing industry)
• what relieves it
• a systemic inquiry to identify secondary causes
• any evidence of a rash, photosensitivity, migraines, joint pains, ulcers, dysphagia, and xerostomia.
• drug treatment history (such as beta­blockers)
• occupational history (such as use of a vibratory tool)
• family history (to check for genetic components to both primary Raynaud phenomenon and systemic sclerosis) (1,2)

On examination:

Focus of examination may vary according to the clues from the history

• hands
• look for colour changes, nail bed changes, and skin integrity.
• sclerodactyly, flexion deformities, tendon friction rubs and calcinosis are present in systemic sclerosis
• digital ulceration if present indicate secondary cause
• feel for limb pulses
• move all joints and assess for pain and contracture
• face
• malar rash, non-scarring alopecia, and oral ulcers suggesting systemic lupus erythematous,
• tightening of the skin seen in systemic sclerosis
• dry skin, telangiectasia, and the salt and pepper appearance of hyperpigmentation and hypopigmentation, which are indicative of systemic sclerosis.
• livedo reticularis, suggesting systemic lupus erythematous or antiphospholipid syndrome
• measure blood pressure in both arms: possible obstructive vascular lesion in the subclavian or axillary arteries
• note that a unilateral Raynaud's phenomenon affects a single limb when there is local pathology e.g. Raynaud's phenomenon in only a single foot may be secondary to a popliteal aneurysm (1,2)

Reference:

• (1) Goundry B, Bell L, Langtree M, Moorthy A. Diagnosis and management of Raynaud's phenomenon. BMJ. 2012;344:e289
• (2) Herrick AL. The pathogenesis, diagnosis and treatment of Raynaud phenomenon. Nat Rev Rheumatol. 2012;8(8):469-79