Raynaud's Phenomenon: Cold, Whitening Fingers, Causes and Treatment

Raynaud's phenomenon is divided into primary and secondary, and the outlook depends on that division. The American Heart Association (AHA, 2026) statement stresses that both forms give similar symptoms but differ in pathogenesis, severity, duration and potential complications. The primary form usually affects women in their second decade of life and runs a benign course. The secondary form usually appears later, in the course of a systemic disease, and in severe cases can lead to finger ischaemia and tissue loss.

In practice, doctors ask a few questions that suggest the secondary form: onset after the age of 30 to 40, asymmetrical attacks or attacks involving single fingers, ulcers or scars on the fingertips, swelling or hardening of the skin of the fingers, joint pain, dry eyes and mouth, rash, swallowing problems or reflux, new drugs. An international expert consensus (Delphi, 2014) proposed a three-step approach to diagnosing Raynaud's phenomenon plus additional criteria for the primary form, to standardise diagnosis. Two tests are key: nailfold capillaroscopy and antibody testing.

This study is the basis of the modern approach to diagnosis: in a person with Raynaud's phenomenon and a normal capillary pattern and no specific antibodies the probability of scleroderma is very low, and in a person with abnormal capillaries and positive antibodies it is very high. The context must be remembered, though: this is a referral-centre cohort, that is, people sent to a specialist, so the proportion who developed scleroderma (12.6%) does not apply to the general population of people with cold fingers. In most young people with typical, benign Raynaud's phenomenon, connective tissue disease never develops.

Nailfold capillaroscopy is a simple, non-invasive test: under magnification, the small capillaries at the base of the nail are viewed. It is done by a rheumatologist or another trained doctor. Testing for antinuclear antibodies (ANA) is usually the first step; a positive result leads to testing for specific antibodies. We write about the symptoms of lupus, one of the diseases that can cause secondary Raynaud's phenomenon, in a knowledge base entry.

The main trigger is cold, but not only cold surroundings: taking things out of the freezer, holding a cold glass, air conditioning and going from a warm room into frost can all set off an attack. The second trigger is emotion, including stress and anxiety, which activate the sympathetic nervous system and constrict the vessels. Tobacco smoking is one of the best-known aggravating factors: nicotine constricts the vessels, so stopping smoking is a key non-drug recommendation.

Attacks can also be worsened by some drugs and substances: non-selective beta-blockers, ergotamine preparations, stimulant drugs (including those used in ADHD), some cancer drugs, interferon and vessel-constricting decongestants in nasal sprays and cold tablets (pseudoephedrine). Triptans, used in migraine, also constrict vessels, so people with Raynaud's phenomenon should discuss their use with a doctor; we write about migraine in a knowledge base entry. The effect of caffeine on attacks is less clear-cut and the evidence limited, so cutting back on coffee is a sensible but unproven step. Do not stop drugs on your own: the decision to change therapy belongs to the doctor.

A separate category is work with vibrating tools (pneumatic hammers, grinders, chainsaws), which can lead to hand-arm vibration syndrome with Raynaud symptoms and sensory disturbance. It concerns people who have done such work for years. Rare, reversible secondary causes, such as hypothyroidism, compression of vessels in the upper chest or blood diseases, are sometimes picked up in the basic work-up.

The authors' conclusion is measured: moderate-quality evidence shows that oral calcium channel blockers are minimally effective at reducing the number of attacks, and high-quality evidence shows they change severity little. In practice this means this is not a drug that 'cures' Raynaud's phenomenon; it may slightly reduce the number of attacks in people for whom they are very troublesome, at the cost of side effects. Another Cochrane review (2021, 15 trials, 635 people) assessed the other vasodilator drugs in primary Raynaud's phenomenon and found the evidence insufficient to recommend them, with some results (for example for ACE inhibitors) even suggesting possible worsening.

The 2026 AHA statement adds a broader context: it notes that there are few clinical trials on treatment, and that management includes lifestyle modification and drug therapy and, in severe cases, botulinum toxin and surgery. In the secondary form, treating the underlying disease is key, because it improves vascular symptoms and prevents complications. The choice of drugs in severe secondary disease, including with ulcers, belongs to a rheumatologist or a vascular specialist.

Blue, cold hands all the time, without distinct attacks or colour change, are more likely acrocyanosis, a constant bluish colour of the hands (less often the feet), usually harmless. Painful red-purple lesions on the fingers after cold exposure (chilblains, pernio) are a different condition, which may coexist with autoimmune disease. Burning, reddened, warm hands or feet that worsen in the heat are erythromelalgia, almost the opposite of Raynaud's phenomenon.

Cold in one hand only, a weak pulse or pain when using the hand may point to narrowing or a blockage of an artery, and with symptoms around the neck and shoulder also to thoracic outlet syndrome. Checking the pulse and, where needed, Doppler ultrasound help tell these situations apart, and we describe the test in the entry on Doppler ultrasound of the vessels. With cold hands and feet accompanied by feeling chilly, fatigue and weight gain, the doctor also checks the thyroid, which we write about in the article on cold intolerance.

Raynaud's phenomenon is an example of a symptom that for most people is a nuisance and for a minority is a signal of disease. A sensible approach is to bring order: did the attacks start early, are they symmetrical, are the fingers free of damage, and if anything raises doubt, have capillaroscopy and serological tests. For the primary form, lifestyle changes and protection from cold work best, and drugs are reserved for severe symptoms, with awareness of their limited effectiveness.