Treatment for Raynaud's

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Introduction

Raynaud syndrome is an auto-immune disorder in which blood vessels in the digits constrict. It usually strikes females between the ages of eighteen and thirty. "Between three to five percent of people are affected." (Harvard, 2003) There is no known cause or cure. (Segala et al, 2003) Clinical features primarily deal with (but are not limited to) the digits of the fingers. Other digits that may be affected include toes, nose, and ear lobes. Exposure to cold and emotional stress triggers the vasoconstriction of the digits. It was originally described by the Catholic, French physician Maurice Raynaud in 1862. In this condition, the vasospastic response is more frequently induced by exposure to cold temperatures and is often accompanied by digital color changes. After onset, a tri-color change [blanching (white), cyanosis (blue), and reactive hyperemia (red)] occurs. "Pallor (blanching) shows vasospasm and loss of arterial blood flow, cyanosis shows the deoxygenation of static venous blood, and rubor (red) shows reactive hyperemia following return of blood flow." (Bowling, 2003) Theories for the causes of Raynaud syndrome include: arterial wall damage, connective tissue disease (CTD), or repetitive use of vibrational tools. (Ko, 2002)

There are various methods of diagnosing Raydaund syndrome. Cold water emersion is one method. In this method, patients' hands are immersed in cold water to observe any clinical features. Another mode of diagnosis looks at medical conditions that are associated with Raynaud syndrome, such as CTD, scleroderma, and lupus. A third technique includes physical examination of the ulnar and radial vessels, nail folds in the capillaries, presence of digital inflammation, sclerodactyly (sleroderma, hardening of the skin, of the fingers and toes), or telangiectasia (chronic dilation of groups of capillaries

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that cause dark red blotches on the skin, usually on the face). Laboratory tests are another consideration of diagnosis. Tests consist of anti-nuclear anti-body (ANA) counts and anti-topoisomerase (an enzyme that reduces super-coiling in DNA by breaking and rejoining one or both strands of DNA). High ANA's and low anti-topoisomerases are found in patients with Raynaud syndrome. (Desai, 2003) "Patients with circulating autoantibodies, antinuclear antibodies, and anti-Scl 70 antibodies are at (an) increased risk of developing a connective tissue disease. Systemic sclerosis is the connective tissue disease most frequently associated with Raynaud's phenomenon." (Bowling, 2003) This syndrome is described as primary Raynaud phenomenon (PRP) if is not associated with another disorder and as secondary Raynaud phenomenon (SRP) if it occurs in association with another disorder.

Statement of the Problem

The episodes that occur due to Raynaud syndrome vary in duration. These episodes vary from a few minutes to a few hours depending on the duration of exposure to cold or the duration of exposure to emotional stress. Prolonged episodes lead to ulcerations of the digits. An ulceration is a section of the digit that has had prolonged cessation of blood flow due to extensive exposure to cold or emotional stress. The last stage of these attacks is when blood flow resumes. This stage is always accompanied by pain.

Raynaud syndrome is not a problem when kept under control. The problem arises when prolonged episodes occur. Prolonged exposure to cold leads to ulcerations of the digits. Continual damage (ulcerations) of the same digit can then lead to amputation.

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The best solution is to keep all episodes under control through medication or to avoid situations in which cold temperatures or emotional stress is involved.

Review of the Literature

Introduction

The purpose of the review of the related literature is to derive the best treatment for Raynaud syndrome. Much research has been collected on this topic. The research collected discusses the following trends in the treatment of Raynaud syndrome: avoidance, medication, and natural supplements.

Treatment: avoidance

The best treatment for Raynaud phenomenon is avoidance of stimuli (prolonged exposure to cold or emotional stress). (Desai, 2003) When cold temperatures can not be avoided, mittens should be worn. Mittens trap warm air better than gloves do. Other conservative measures include layered clothing, heated socks, specially made gloves (electric, wool, cashmere, ceramic-impregnated), or occupational avoidance to vibration. Stimuli can also include smoking because smoking causes vasoconstriction, decreasing blood flow to the fingers and toes. Therefore smoking should also be avoided. (Bowling 2003) These conservative measures work best on patients with PRP.

In a study by Ko (2002), it was determined that ceramic-impregnated garments only showed slight improvement in patients with Raynaud syndrome. Ko ran a placebo-controlled experiment using ceramic-impregnated gloves. Patients were recruited through a newspaper ad in Canada. Respondents were then given a "Pal" questionnaire (see table 1). This type of screening required a mandatory yes answer to question one

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and a total score greater than four. Nintey-three people qualified for the study. They were then examined at Sunnybrook and the Canadian Centre for Integrative Medicine. Other conditions were also considered. The researchers looked at caffeine and alcohol consumption, use of birth control pills, and different medications taken. Half the participants were then supplied with ceramic-impregnated "thermoflow" gloves and the other half were supplied with placebo (cotton) gloves. The look, feel, and smell of the gloves were similar. The study was conducted in two three-month segments. Tests used in the study were skin temperature measurements, Jamar grip strength, a hand dexterity test, and Phalen's sign (a wrist flexion test). Patients also kept a diary of Raynaud syndrome attacks. Pre and post treatment evaluations were conducted. In the group given the ceramic-impregnated gloves, the test results indicated a slight decrease in the visual analogue scale (a measure of pain), a slight decrease in disability of the arm, shoulder and hand, a slight increase in finger temperature, as well as a slight increase in grip strength. The placebo group showed no