Raynaud's phenomenon: the Australian general practice guide

Raynaud’s phenomenon is a common reason people present to their GP with cold-sensitive hands. Most cases are benign and manageable, but distinguishing primary from secondary Raynaud’s is critical — secondary cases may herald a serious connective tissue disease that needs early identification and treatment.

This article explains how Raynaud’s is diagnosed, what investigations are needed, and what can be done to reduce attacks and protect the fingers from damage.

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A. Core clinical framework

What happens in Raynaud’s

Raynaud’s phenomenon is episodic reversible vasospasm of the small arteries and arterioles of the digits, triggered by cold exposure or emotional stress. The vasospasm reduces blood flow, causing ischaemia, and the triphasic colour change reflects the sequential physiological events:

• White (pallor): arteriolar vasospasm causes sharp reduction in blood flow.
• Blue (cyanosis): residual blood becomes deoxygenated, producing a deep blue or purple discolouration.
• Red (erythema): vasospasm resolves, blood flow returns with reactive hyperaemia, and the digit flushes red — often with burning, throbbing pain.

The colour change is typically sharply demarcated — there is a clear line between affected and normal skin. Not every attack passes through all three phases. Attacks last minutes to over an hour and resolve spontaneously with rewarming.

The fingers are most commonly affected; toes, ears, nose, and (in breastfeeding women) nipples can also be involved.

Primary versus secondary Raynaud’s

The most important clinical distinction is between primary and secondary Raynaud’s phenomenon:

Primary Raynaud’s (~80% of cases) has no identifiable underlying cause. It is a constitutional vasomotor sensitivity. It typically:

• Affects young women (peak onset 15–30 years)
• Is bilateral and symmetric
• Does not cause digital ulcers or tissue damage
• Has normal nailfold capillaroscopy
• Has no autoimmune markers

It is a benign condition that does not progress to disability, though it can cause significant discomfort and quality-of-life impact in cold climates.

Secondary Raynaud’s (~20% of cases) is caused by an underlying condition. The most important causes in Australian general practice are:

• Connective tissue disease — systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), Sjögren’s syndrome, mixed connective tissue disease, dermatomyositis/polymyositis, rheumatoid arthritis
• Vibration-induced injury — Raynaud’s in workers using vibrating tools (hand-arm vibration syndrome)
• Drug-induced — beta-blockers, amphetamines, cocaine, ergotamine, chemotherapy (bleomycin, cisplatin)
• Thoracic outlet syndrome — in younger people with positional upper limb symptoms
• Hypothyroidism — check TSH if not already done

Secondary Raynaud’s tends to be more severe, asymmetric, and may be associated with digital ulcers, which are an indicator of critical ischaemia and significant microvascular damage.

Features suggesting secondary Raynaud’s

The RACGP and NICE CKS both highlight the following clinical features as raising suspicion for secondary disease:

• Onset after age 30
• Asymmetric or very severe attacks
• Digital pitting scars, ulcers, or gangrene
• Abnormal nailfold capillaroscopy (dilated, distorted, or absent capillary loops)
• Positive ANA or disease-specific antibodies
• Associated symptoms: joint swelling, skin tightening, dry eyes or mouth, dysphagia, dyspnoea, skin rash

Investigations

For any presentation with Raynaud’s phenomenon, eTG Complete recommends:

• Nailfold capillaroscopy — examination of the nailfold with a dermatoscope or ophthalmoscope. Structural abnormalities (giant capillaries, haemorrhages, avascular areas) strongly suggest secondary Raynaud’s and connective tissue disease. This can be performed by the GP in practice.
• ANA (antinuclear antibody) — screening test for connective tissue disease. A positive ANA warrants an ENA panel.
• ENA panel — includes anti-Scl-70 (anti-topoisomerase I, specific for diffuse systemic sclerosis), anti-centromere antibody (specific for limited systemic sclerosis/CREST), anti-Ro, anti-La, anti-Sm, anti-U1-RNP.
• FBC, ESR, CRP — baseline inflammatory markers and anaemia screening.
• Thyroid function (TSH) — to exclude hypothyroidism as a contributing cause.
• Urinalysis — proteinuria in lupus nephritis.

In primary Raynaud’s, all investigations are normal. In secondary Raynaud’s due to systemic sclerosis, anti-Scl-70 or anti-centromere antibodies are often positive, and nailfold capillaroscopy is abnormal.

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B. Evidence review

The Cochrane review by Stewart M et al. (2018) on oral vasodilators for primary Raynaud’s phenomenon is the definitive evidence base for pharmacological treatment. Key findings:

• Calcium channel blockers (CCBs) — nifedipine and amlodipine — are the best-supported first-line pharmacological agents. They reduce the frequency and severity of attacks compared to placebo, with an effect size that is clinically meaningful. Nifedipine modified-release 30–60 mg daily is the most studied.
• Side effects of CCBs are dose-dependent and include headache, facial flushing, and peripheral ankle oedema. A lower starting dose (nifedipine MR 30 mg or amlodipine 5 mg) with uptitration as needed reduces side-effect burden.

For secondary Raynaud’s due to systemic sclerosis:

• PDE5 inhibitors (sildenafil, tadalafil) — the SEDUCE trial demonstrated significant reduction in Raynaud’s attack frequency and severity with sildenafil in systemic sclerosis-related Raynaud’s.
• Bosentan (endothelin receptor antagonist) — PBS Authority-listed for the prevention of new digital ulcers in systemic sclerosis. It reduces the number of new digital ulcers but does not accelerate healing of established ones.
• Macitentan — also an endothelin receptor antagonist with PBS Authority listing for systemic sclerosis digital ulcer prophylaxis in specialist hands.
• Intravenous iloprost — reserved for severe acute digital ischaemia or refractory digital ulcers; administered in a specialist inpatient or day hospital setting.

What the evidence does not support:

• Routine use of vasodilators for mild primary Raynaud’s without first trying cold avoidance and non-pharmacological measures.
• Alpha-blockers and other agents have limited evidence in primary Raynaud’s.

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C. Treatment — staged approach

Non-pharmacological (all cases, first line)

Non-pharmacological strategies are the foundation of Raynaud’s management and effective in many people with mild primary Raynaud’s:

• Cold avoidance: avoid cold environments when possible; pre-warm car, kitchen surfaces, and tools in winter.
• Layering: keep the whole body warm, not just the hands — central warming prevents the reflex vasoconstriction that triggers attacks.
• Insulated gloves and mittens: worn during cold exposure and when handling cold items (refrigerator, frozen goods). Gloves with hand-warmer pockets can be helpful.
• Rewarming technique during attacks: place hands in warm (not hot) water or under the axillae; avoid rubbing, which can worsen pain.
• Smoking cessation: nicotine causes peripheral vasoconstriction and worsens Raynaud’s. Smoking cessation support is an important part of management.
• Caffeine and stimulant reduction: caffeine and amphetamines cause vasoconstriction; reduce where possible.
• Stress management: emotional stress is a trigger; stress reduction techniques may reduce attack frequency.
• Review of medications: beta-blockers and other vasoconstrictive drugs should be reviewed and changed if possible.

Pharmacological (moderate to severe or not responding to non-pharmacological measures)

eTG Complete recommends a stepped approach:

Step 1 — Calcium channel blocker (first-line):

• Nifedipine modified-release 30 mg daily — starting dose; uptitrate to 60 mg daily if needed and tolerated.
• Amlodipine 5 mg daily — alternative; once-daily dosing and often better tolerated; uptitrate to 10 mg daily.
• Duration: continue through winter months; consider tapering in summer if attacks remit.

Step 2 (secondary Raynaud’s, specialist-initiated):

• Sildenafil or tadalafil for systemic sclerosis-related Raynaud’s.
• Bosentan — PBS Authority for prevention of new digital ulcers in systemic sclerosis; requires specialist initiation and monitoring (LFTs monthly — hepatotoxicity risk).
• IV iloprost — for acute digital ischaemia or refractory ulcers.

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D. Australian general practice operations

MBS items

Raynaud’s presentations are managed under standard GP attendance items:

• Items 23, 36, 44 — Level B, C, and D GP consultations for assessment and ongoing management.
• Item 65070 / 65088 — immunology pathology (ANA, ENA) for connective tissue disease screening.
• Item 65060 — complement levels if SLE is suspected.
• Item 69306 — nailfold capillaroscopy by a dermatologist or rheumatologist.
• Rheumatology referral — for confirmed or suspected connective tissue disease; item 110/112 for specialist consultation.
• Item 715 — ATSI Health Assessment where relevant.

PBS prescribing

• Nifedipine modified-release (30 mg and 60 mg) — General Schedule; no Authority required for Raynaud’s.
• Amlodipine — General Schedule.
• Sildenafil — General Schedule for pulmonary arterial hypertension; in Raynaud’s often prescribed as “private” or under rheumatologist authority.
• Bosentan (Tracleer) — PBS Authority Required: “systemic sclerosis with active digital ulcers to reduce the frequency of new digital ulcers.” Initiated by a rheumatologist or specialist physician; GP continues on Continuing Authority once stabilised.
• Macitentan — PBS Authority Required (similar indication to bosentan for systemic sclerosis digital ulcers).

Specialist referral pathways

• Rheumatology: for any features of secondary Raynaud’s — positive ANA, abnormal capillaroscopy, digital ulcers, skin changes, joint disease. Urgent referral for acute digital ischaemia.
• Vascular surgery: for digital ulcers not healing, critical ischaemia, or consideration of sympathectomy.
• Occupational medicine: for vibration-induced Raynaud’s (hand-arm vibration syndrome) — relevant for WorkCover and workplace modification.
• Dermatology: for skin involvement in systemic sclerosis (calcinosis, telangiectasia, skin tightening).

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E. Special populations

Systemic sclerosis (scleroderma)

Secondary Raynaud’s is the presenting feature in over 90 per cent of people with systemic sclerosis, often preceding other features by months to years. Australian Rheumatology Association guidelines recommend annual screening for pulmonary arterial hypertension (PAH) — echocardiography, PFTs, and DLCO — in all patients with systemic sclerosis, as PAH is a leading cause of mortality. Early rheumatology involvement is essential.

Pregnancy

Primary Raynaud’s often improves during pregnancy due to the physiological increase in blood volume and peripheral vasodilatation. Nifedipine is used for other indications in pregnancy and is generally considered safe; however, decisions about pharmacological management during pregnancy should be made by the treating GP or obstetrician.

Young women

Primary Raynaud’s is most common in young women aged 15–30 years, many of whom will present before the diagnosis of any underlying connective tissue disease. Serial annual review with repeat ANA and capillaroscopy every three to five years is reasonable if symptoms are progressive or if any new connective tissue disease features emerge. Most will remain primary.

Occupational exposure

Workers using vibrating tools (power tools, grinders, jackhammers) can develop vibration-induced Raynaud’s (hand-arm vibration syndrome). This is a notifiable occupational disease in some states. Workplace modification, vibration exposure reduction, and warm gloves are the mainstays. WorkCover referral may be relevant.

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When to escalate

Seek urgent or same-day review for:

• Digital artery occlusion: a digit that remains cold, white, or numb for more than four hours without rewarming — this may represent acute ischaemia requiring urgent vascular assessment.
• Digital ulceration or gangrene: digital ulcers in Raynaud’s indicate critical ischaemia and require urgent specialist input (rheumatology + vascular surgery).
• New Raynaud’s with rapid systemic progression: rapidly developing skin tightening, dyspnoea, or dysphagia alongside new Raynaud’s may indicate early diffuse systemic sclerosis — urgent rheumatology referral.

Routine specialist referral is appropriate for:

• Positive ANA or ENA with clinical features consistent with connective tissue disease.
• Abnormal nailfold capillaroscopy on GP assessment.
• Severe or asymmetric attacks not responding to oral CCBs.
• Onset after age 30 in a patient without a clear primary Raynaud’s history.

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What this article is and is not

This article provides general patient education about Raynaud’s phenomenon based on current Australian and international guidelines. It is not a substitute for clinical assessment. The distinction between primary and secondary Raynaud’s, the choice and dose of medication, and decisions about specialist referral all depend on your individual clinical findings.

Nothing in this article constitutes a recommendation to start or change any medication. If your fingers are turning white and you are concerned, see your GP.

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Sources cited

• Stewart M et al. — Oral vasodilators for primary Raynaud’s phenomenon (Cochrane 2018)
• RACGP — Raynaud’s phenomenon in general practice
• eTG complete — Raynaud’s phenomenon
• NICE CKS — Raynaud’s phenomenon
• Australian Rheumatology Association — Raynaud’s
• Nihtyanova SI et al. — Prediction of pulmonary complications and mortality in systemic sclerosis (Ann Rheum Dis 2014)
• SEDUCE trial — Sildenafil in Raynaud’s secondary to systemic sclerosis
• PBS Schedule — Bosentan for digital ulcers in systemic sclerosis
• Arthritis Australia — Raynaud’s phenomenon
• HealthDirect Australia — Raynaud’s phenomenon