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Posted By: Richard S. Pope, PA-C, MPAS
February 12, 2021
Color changes in patients' fingertips during cold weather can be confusing. It is important to distinguish Raynaud's phenomenon, as it can be associated with autoimmune disease.
Bluish/purplish discoloration on exposure to cold is suggestive of Raynaud's, but it is also consistent with acrocyanosis. These symptoms are present in up to 75% of women and are merely a vasospastic response to cold temperatures. Many rheumatologists categorize a two-phase color change as Raynaud's, however this is less worrisome than full-blown triphasic changes. Full, triphasic Raynaud's includes blanching on cold and a reactive hyperemia followed by a dusky cyanosis. In these patients it is important to do a nailfold capillaroscopy looking for tissue compromise—specifically hemorrhages and dilations, which are more worrisome findings due to the potential for tissue damage. Additionally, lab tests should be performed to rule autoimmune diseases in or out: This would include an antinuclear antibody (ANA) titer, followed by reflex testing of extractable nuclear antigens if the ANA were positive; staining pattern; CBC; comprehensive metabolic panel; inflammatory markers; thyroid stimulating hormone; and creatine kinase, if muscle symptoms are present.
Triphasic discoloration is of more concern especially when it is associated with any one of the following features:
- Strongly positive ANA
- Evidence of tissue ischemia, such as digital pulp scars
- Digital ulcers
- Periungual erythema
Patients with the above features are at higher risk for developing disease in other organ systems. The differential diagnosis here is scleroderma, dermatomyositis, systemic lupus erythematosus, or mixed connective tissue disease. Most NPs and PAs should be familiar with lifestyle management techniques that can relieve much of the painful symptomatology. Further management commonly includes calcium channel blockers and other medications. You can access both lifestyle and medication management via a comprehensive review of this topic on the Mayo Clinic website.
- Mayo Clinic. Raynaud's disease. www.mayoclinic.org/diseases-conditions/raynauds-disease/diagnosis-treatment/drc-20363572. Accessed February 11, 2021.
Post image (Example of Raynaud syndrome on the hand of a female airman) attributed to Profpedia at English Wikipedia. No alterations were made to the image by PCE. License: commons.wikimedia.org/wiki/Commons:GNU_Free_Documentation_License,_version_1.2.