Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Raynaud phenomenon and digital ischaemia
Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Critical digital ischaemia
Persistent rest pain, pallor or cyanosis, sensory loss, a non-healing ulcer, necrosis or absent pulses represents threatened tissue rather than an uncomplicated reversible Raynaud attack.
Action: Arrange same-day vascular and rheumatology assessment, provide analgesia and warmth, stop vasoconstrictors, assess proximal flow and thrombosis, and begin specialist intravenous vasodilation or revascularisation without waiting for outpatient antibody results.
Synopsis
Distinguish primary Raynaud phenomenon from secondary vasculopathy, identify threatened tissue early, investigate connective-tissue and occlusive causes proportionately, and escalate from protection and oral vasodilation to emergency digital rescue.
Raynaud phenomenon is episodic, sharply demarcated digital colour change triggered by cold or emotion; not every patient experiences all three white, blue and red phases.
Primary Raynaud is usually young-onset, symmetrical, thumb-sparing, reversible and non-ulcerating, with normal pulses, nailfolds and systemic assessment.
Secondary clues are later onset, severe pain, asymmetry, thumb involvement, ulcer or pit, abnormal nailfold capillaries, systemic features, absent pulses or relevant medicine and occupational exposure.
Critical ischaemia is persistent rather than episodic: rest pain, fixed pallor or cyanosis, numbness, ulcer progression or necrosis needs same-day care.
First-line care is whole-body warmth, gloves, rapid rewarming, smoking cessation, avoidance of vibration and review of beta blockers, stimulants, decongestants and other vasoconstrictors.
For troublesome uncomplicated attacks, modified-release nifedipine is the usual first oral medicine; titrate against attack burden, pressure, headache, oedema and reflux.
Sildenafil is a specialist next option for severe secondary Raynaud or digital ulcers; never combine it with nitrates or riociguat.
Intravenous iloprost is an urgent specialist treatment for severe refractory attacks, ulcer progression or threatened tissue, with continuous pressure and adverse-effect monitoring.
Use ANA, disease-specific antibodies and nailfold capillaroscopy when secondary disease is plausible, but pursue duplex or angiography when proximal or focal occlusion is suspected.
Antiplatelet and anticoagulant treatment is not routine for primary vasospasm; use it only for a defined thrombotic, embolic or vascular indication.
Key red flags
Pain or colour change that does not reverse with warming, new sensory loss, weakness, ulceration or black tissue requires urgent digital-ischaemia care.
Absent or asymmetric upper-limb pulses, major inter-arm pressure difference or acute onset suggests embolic, thrombotic or large-vessel obstruction.
New Raynaud after age thirty, severe asymmetry, thumb involvement, abnormal nailfolds, puffy or tight skin, inflammatory features or systemic illness suggests secondary disease.
Fever, purulence, spreading erythema or rapidly progressive pain around an ulcer requires infection and osteomyelitis assessment alongside perfusion care.
Pregnancy with severe vasculopathy, hypertension or renal symptoms requires specialist review before changing vasoactive or renin-angiotensin medicines.
Fixed digital ischaemia
Persistent rest pain, non-blanching pallor or cyanosis, paraesthesia, pulp loss or necrosis indicates threatened tissue rather than ordinary vasospasm.
Proximal occlusive pattern
A single hand, absent pulse, bruit, pressure asymmetry or acute continuous symptoms suggests embolus, thrombosis, thoracic outlet or arterial injury.
Investigation priorities
01
History, pulses and vascular examinationFirst step
Separate episodic small-vessel vasospasm from fixed digital or proximal arterial disease.
Management branches
First-line classificationSeparate primary from secondary
Episodic cold- or stress-induced digital colour change is reported without current fixed ischaemia.
Document onset, symmetry, thumb involvement, phases, duration, pain, reversibility, ulcers, systemic symptoms, medicines, smoking, work and vibration exposure.
Examine pulses, pressures, skin, nailfolds, joints and connective-tissue signs; reserve antibodies and capillaroscopy for a secondary phenotype.
Diagnose primary Raynaud only when examination and trajectory are reassuring, and give return advice for persistent pain, asymmetry, ulcer or systemic change.
Preferred symptom treatmentProtect first, then vasodilate
Reversible attacks impair function despite trigger reduction and warming.
Optimise whole-body warmth, gloves, skin care, smoking cessation and removal of avoidable vasoconstrictors or vibration.
Start modified-release nifedipine and titrate to benefit while monitoring pressure, dizziness, oedema, headache and reflux.
If ineffective or not tolerated, refer severe secondary disease for sildenafil or another specialist alternative rather than uncontrolled polypharmacy.
Key medicines
Nifedipine modified releaseGive 30 mg by mouth once a day initially. According to attack response, blood pressure and the selected modified-release product, raise the dose, commonly to 60 mg once daily.Monitor headache, flushing, ankle oedema, tachycardia, dizziness and reflux; reduce or stop for symptomatic hypotension. Review CYP3A4 interactions, pregnancy and gastrointestinal obstruction risk for the selected product, and do not crush modified-release tablets.
SildenafilFor severe secondary Raynaud or digital ulceration, a common specialist off-label regimen is 20 mg orally three times daily, titrated only within the vascular or systemic-sclerosis plan.Never combine with nitrates or riociguat. Review hypotension, cardiac disease, renal or hepatic impairment, pregnancy, CYP3A4 interactions and visual, hearing or prolonged-erection adverse effects.
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.