Raynaud's
Phenomenon and Ulcerations (Question and Answer)
by Philip Clements, M.D., UCLA School of Medicine,
Department of Rheumatology, (originally published in
"Scleroderma Voice," Spring 2001)
Question: I have very active Raynaud's
with seven episodes of ulcerations. I have secondary
CREST syndrome, mainly digital.
My medications are Nifedipine (30 mg), Pentoxifilline
(400 mg, three times/day), Ecotrin (86 mg, three times/day),
and zinc. My blood pressure is normally around 100.
Is there anything else we could be looking at to control
the Raynaud's? Channel blockers did not work, and a
sympathectomy gave only temporary relief.
Ms. J.B., Annville, Pa.
 |
| Philip
Clements , M.D., M.P.H. |
Answer: Ulcerations of the fingertips
and elsewhere in the body are very common in systemic
sclerosis, particularly in cold weather or if the person
works in a cold environment.
Severe ulcerations or necrotic areas of the fingers
(dry gangrene evidenced by a black scab and by shrinking
of the tissues under the scab) may be a sign that there
is blockage of an artery to the hand in addition to
the temporary artery spasm of Raynaud's.
There are two major arteries which supply blood to
the hand (the radial and ulnar arteries) which can be
occluded or blocked by the scleroderma process.
The blood flow to the hand by the two arteries can
be easily examined using a simple clinical test called
the Alien test. The doctor presses firmly on both arteries
at the wrist while the patient clenches the fist.
The doctor then asks the patient to relax the fist
while he releases the pressure over one of the arteries.
The physician counts the seconds until the hand "pinks
up."
The other artery is tested the same way. If there
is a marked delay in "pinking up," it suggests
that that artery is occluded.
When fingertip necrosis appears in systemic sclerosis,
it is not uncommon to find that one (usually the ulnar
artery) or both arteries are occluded. The occlusion
can be confirmed by an x-ray (anteriogram).
The person may benefit from evaluation and treatment
by a vascular surgeon, who may be able to bypass the
artery obstruction with a vein or fabric graft, or surgically
interrupt the sympathetic nerves in the hands, causing
blood vessels to relax. That may improve the circulation
to the fingers. |
