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.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical 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.
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.
Fixed digital ischaemia
Persistent rest pain, non-blanching pallor or cyanosis, paraesthesia, pulp loss or necrosis indicates threatened tissue rather than ordinary vasospasm.
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.
Preferred symptom treatmentProtect first, then vasodilate
Reversible attacks impair function despite trigger reduction and warming.
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.
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.
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.