Cleveland Clinic Journal of Medicine

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

A 40-year-old man was brought to the emergency department with altered mental status. His roommate had found him lying unconscious in snow on the lawn outside his residence. When the emergency medical services team arrived, they recorded a core body temperature of 28.3°C (82.9°F) and instituted advanced cardiac life support.

During transit to the hospital, the patient’s heart rhythm changed from asystole to ventricular fibrillation, and defibrillation was performed twice.

Upon his arrival at the emergency room, advanced life support was continued, resulting in return of spontaneous circulation, with slow, wide-complex QRS rhythm noted on electrocardiography (ECG).

On examination, the patient’s pupils were fixed and dilated. The extremities were cold to palpation. The core body temperature dropped to 27.7°C (81.9°F).

Laboratory test results showed severe acidemia (arterial pH 6.8), elevated aspartate aminotransferase and alanine aminotransferase levels, and elevated creatinine and troponin. The troponin was measured 3 times and rose from 0.8 ng/mL to 0.9 ng/mL. A urine toxicology screen was positive for cannabinoids and cocaine.

ECG revealed J-point elevation (Osborn waves) in the precordial leads (Figure 1). A baseline electrocardiogram in the medical record from a previous admission had been normal.

An aggressive hypothermia protocol was initiated, but the patient died despite resuscitation efforts.

HYPOTHERMIA AND HEART RHYTHMS

Hypothermia—a core body temperature below 35°C (95°F)—causes generalized slowing of impulse conduction through cardiac tissues, shown on ECG as a prolongation of the PR, RR, QRS, and QT intervals.¹

A characteristic feature is elevation of the J point, also called the J wave or Osborn wave, most prominent in precordial leads V₂ to V₅ and caused by abnormal membrane repolarization in the early phase. The degree of hypothermia correlates linearly with the amplitude of the Osborn wave.^2,3

Laboratory tests can identify complications such as rhabdomyolysis, spontaneous bleeding, and lactic acidosis. Moderate to severe hypothermia may cause prolongation of all ECG intervals. Management requires resuscitation and rewarming.

Conditions to consider in the differential diagnosis are Brugada syndrome, hypercalcemia, and early repolarization syndrome.

A 40-year-old man was brought to the emergency department with altered mental status. His roommate had found him lying unconscious in snow on the lawn outside his residence. When the emergency medical services team arrived, they recorded a core body temperature of 28.3°C (82.9°F) and instituted advanced cardiac life support.

During transit to the hospital, the patient’s heart rhythm changed from asystole to ventricular fibrillation, and defibrillation was performed twice.

Upon his arrival at the emergency room, advanced life support was continued, resulting in return of spontaneous circulation, with slow, wide-complex QRS rhythm noted on electrocardiography (ECG).

On examination, the patient’s pupils were fixed and dilated. The extremities were cold to palpation. The core body temperature dropped to 27.7°C (81.9°F).

Laboratory test results showed severe acidemia (arterial pH 6.8), elevated aspartate aminotransferase and alanine aminotransferase levels, and elevated creatinine and troponin. The troponin was measured 3 times and rose from 0.8 ng/mL to 0.9 ng/mL. A urine toxicology screen was positive for cannabinoids and cocaine.

ECG revealed J-point elevation (Osborn waves) in the precordial leads (Figure 1). A baseline electrocardiogram in the medical record from a previous admission had been normal.

An aggressive hypothermia protocol was initiated, but the patient died despite resuscitation efforts.

HYPOTHERMIA AND HEART RHYTHMS

Hypothermia—a core body temperature below 35°C (95°F)—causes generalized slowing of impulse conduction through cardiac tissues, shown on ECG as a prolongation of the PR, RR, QRS, and QT intervals.¹

A characteristic feature is elevation of the J point, also called the J wave or Osborn wave, most prominent in precordial leads V₂ to V₅ and caused by abnormal membrane repolarization in the early phase. The degree of hypothermia correlates linearly with the amplitude of the Osborn wave.^2,3

Laboratory tests can identify complications such as rhabdomyolysis, spontaneous bleeding, and lactic acidosis. Moderate to severe hypothermia may cause prolongation of all ECG intervals. Management requires resuscitation and rewarming.

Conditions to consider in the differential diagnosis are Brugada syndrome, hypercalcemia, and early repolarization syndrome.

A 40-year-old man was brought to the emergency department with altered mental status. His roommate had found him lying unconscious in snow on the lawn outside his residence. When the emergency medical services team arrived, they recorded a core body temperature of 28.3°C (82.9°F) and instituted advanced cardiac life support.

During transit to the hospital, the patient’s heart rhythm changed from asystole to ventricular fibrillation, and defibrillation was performed twice.

Upon his arrival at the emergency room, advanced life support was continued, resulting in return of spontaneous circulation, with slow, wide-complex QRS rhythm noted on electrocardiography (ECG).

On examination, the patient’s pupils were fixed and dilated. The extremities were cold to palpation. The core body temperature dropped to 27.7°C (81.9°F).

Laboratory test results showed severe acidemia (arterial pH 6.8), elevated aspartate aminotransferase and alanine aminotransferase levels, and elevated creatinine and troponin. The troponin was measured 3 times and rose from 0.8 ng/mL to 0.9 ng/mL. A urine toxicology screen was positive for cannabinoids and cocaine.

ECG revealed J-point elevation (Osborn waves) in the precordial leads (Figure 1). A baseline electrocardiogram in the medical record from a previous admission had been normal.

An aggressive hypothermia protocol was initiated, but the patient died despite resuscitation efforts.

HYPOTHERMIA AND HEART RHYTHMS

Hypothermia—a core body temperature below 35°C (95°F)—causes generalized slowing of impulse conduction through cardiac tissues, shown on ECG as a prolongation of the PR, RR, QRS, and QT intervals.¹

A characteristic feature is elevation of the J point, also called the J wave or Osborn wave, most prominent in precordial leads V₂ to V₅ and caused by abnormal membrane repolarization in the early phase. The degree of hypothermia correlates linearly with the amplitude of the Osborn wave.^2,3

Laboratory tests can identify complications such as rhabdomyolysis, spontaneous bleeding, and lactic acidosis. Moderate to severe hypothermia may cause prolongation of all ECG intervals. Management requires resuscitation and rewarming.

Conditions to consider in the differential diagnosis are Brugada syndrome, hypercalcemia, and early repolarization syndrome.

A 41-year-old woman presented with coughing, wheezing, and painful subcutaneous nodules on her legs. She had presented 6 years ago with similar nodules and enlarged retroauricular, occipital, and maxillary lymph nodes. At that time, biopsy study of submaxillary lymph nodes and skin showed nonnecrotizing granulomas, with negative microbiology studies. Chest radiography and spirometry were normal. A diagnosis of sarcoidosis was made. Treatment was offered but refused.

Based on this history, computed tomography of the thorax and abdomen was performed and showed mediastinal and hilar lymphadenopathy, small bilateral lung nodules, and osseous cystic areas in both iliac blades. Magnetic resonance imaging (MRI) showed numerous discrete lesions in both iliac bones (Figure 1). Biopsy study of iliac bone revealed preserved architecture with no evidence of malignancy or granulomas.

Radiography of the hands showed an osseous lytic lesion in the third proximal phalanx of the right hand. No other radiographic abnormalities were noted.

The clinical and radiographic features and the patient’s clinical course were consistent with osseous sarcoidosis. She was started on methotrexate and a low-dose corticosteroid and was symptom-free at 12-month follow-up. Follow-up MRI showed reduction in the lymphadenopathies and stabilization of the bone lesions.

SARCOIDOSIS AND BONE

Sarcoidosis is a systemic granulomatous disease that involves the lung in more than 90% of cases. Skeletal involvement has been reported in 1% to 14% of patients.^1,2 Typical osseous involvement is cystic osteitis of the phalangeal bones of the hands and feet, but any part of the skeleton may be involved.³

Bone sarcoidosis is usually asymptomatic and is discovered incidentally. The diagnosis of sarcoidosis has usually been established clinically before bone lesions are detected on MRI. However, sarcoidosis-related bone lesions resembling bone metastases on MRI may be the initial presentation. The presence of intralesional fat has been described as a feature that excludes malignancy. 

No treatment has been shown to be of benefit.⁴ Sarcoidosis is a diagnosis of exclusion and radiographic lytic bone features are not specific, so a neoplastic cause (such as primary osteoblastoma, metastasis, or multiple myeloma) must always be ruled out, as well as other bone conditions such as osteomyelitis or bone cyst.

A 41-year-old woman presented with coughing, wheezing, and painful subcutaneous nodules on her legs. She had presented 6 years ago with similar nodules and enlarged retroauricular, occipital, and maxillary lymph nodes. At that time, biopsy study of submaxillary lymph nodes and skin showed nonnecrotizing granulomas, with negative microbiology studies. Chest radiography and spirometry were normal. A diagnosis of sarcoidosis was made. Treatment was offered but refused.

Based on this history, computed tomography of the thorax and abdomen was performed and showed mediastinal and hilar lymphadenopathy, small bilateral lung nodules, and osseous cystic areas in both iliac blades. Magnetic resonance imaging (MRI) showed numerous discrete lesions in both iliac bones (Figure 1). Biopsy study of iliac bone revealed preserved architecture with no evidence of malignancy or granulomas.

Radiography of the hands showed an osseous lytic lesion in the third proximal phalanx of the right hand. No other radiographic abnormalities were noted.

The clinical and radiographic features and the patient’s clinical course were consistent with osseous sarcoidosis. She was started on methotrexate and a low-dose corticosteroid and was symptom-free at 12-month follow-up. Follow-up MRI showed reduction in the lymphadenopathies and stabilization of the bone lesions.

SARCOIDOSIS AND BONE

Sarcoidosis is a systemic granulomatous disease that involves the lung in more than 90% of cases. Skeletal involvement has been reported in 1% to 14% of patients.^1,2 Typical osseous involvement is cystic osteitis of the phalangeal bones of the hands and feet, but any part of the skeleton may be involved.³

Bone sarcoidosis is usually asymptomatic and is discovered incidentally. The diagnosis of sarcoidosis has usually been established clinically before bone lesions are detected on MRI. However, sarcoidosis-related bone lesions resembling bone metastases on MRI may be the initial presentation. The presence of intralesional fat has been described as a feature that excludes malignancy. 

No treatment has been shown to be of benefit.⁴ Sarcoidosis is a diagnosis of exclusion and radiographic lytic bone features are not specific, so a neoplastic cause (such as primary osteoblastoma, metastasis, or multiple myeloma) must always be ruled out, as well as other bone conditions such as osteomyelitis or bone cyst.

A 41-year-old woman presented with coughing, wheezing, and painful subcutaneous nodules on her legs. She had presented 6 years ago with similar nodules and enlarged retroauricular, occipital, and maxillary lymph nodes. At that time, biopsy study of submaxillary lymph nodes and skin showed nonnecrotizing granulomas, with negative microbiology studies. Chest radiography and spirometry were normal. A diagnosis of sarcoidosis was made. Treatment was offered but refused.

Based on this history, computed tomography of the thorax and abdomen was performed and showed mediastinal and hilar lymphadenopathy, small bilateral lung nodules, and osseous cystic areas in both iliac blades. Magnetic resonance imaging (MRI) showed numerous discrete lesions in both iliac bones (Figure 1). Biopsy study of iliac bone revealed preserved architecture with no evidence of malignancy or granulomas.

Radiography of the hands showed an osseous lytic lesion in the third proximal phalanx of the right hand. No other radiographic abnormalities were noted.

The clinical and radiographic features and the patient’s clinical course were consistent with osseous sarcoidosis. She was started on methotrexate and a low-dose corticosteroid and was symptom-free at 12-month follow-up. Follow-up MRI showed reduction in the lymphadenopathies and stabilization of the bone lesions.

SARCOIDOSIS AND BONE

Sarcoidosis is a systemic granulomatous disease that involves the lung in more than 90% of cases. Skeletal involvement has been reported in 1% to 14% of patients.^1,2 Typical osseous involvement is cystic osteitis of the phalangeal bones of the hands and feet, but any part of the skeleton may be involved.³

Bone sarcoidosis is usually asymptomatic and is discovered incidentally. The diagnosis of sarcoidosis has usually been established clinically before bone lesions are detected on MRI. However, sarcoidosis-related bone lesions resembling bone metastases on MRI may be the initial presentation. The presence of intralesional fat has been described as a feature that excludes malignancy. 

No treatment has been shown to be of benefit.⁴ Sarcoidosis is a diagnosis of exclusion and radiographic lytic bone features are not specific, so a neoplastic cause (such as primary osteoblastoma, metastasis, or multiple myeloma) must always be ruled out, as well as other bone conditions such as osteomyelitis or bone cyst.

Raynaud phenomenon is an overactive vascular response to cold and emotional stress that results in cutaneous color changes and sensory symptoms of the digits (Figure 1). It can occur in isolation as primary Raynaud phenomenon or secondary to another disease process. It is thought to be triggered by a heightened sympathetic vasoconstrictive response of small arteriovenous anastomoses in the fingers, toes, ears, and tip of the nose. These structures play a key role in maintaining a stable core body temperature by cutaneous thermoregulation.¹

Secondary Raynaud phenomenon can be seen with a wide array of systemic conditions as well as environmental and drug exposures. It is a frequent feature of autoimmune rheumatic conditions such as systemic sclerosis, mixed connective tissue disease, systemic lupus erythematosus, and dermatomyositis. Less commonly, cryoproteinemias, paraneoplastic syndromes, hypothyroidism, and carpal tunnel syndrome can be associated with or cause Raynaud phenomenon. Vibratory trauma (eg, from using a jackhammer) and drugs (eg, vasopressors, stimulants, ergots, chemotherapeutic agents) can also cause Raynaud phenomenon.¹

A variety of disorders that cause vasospasm or vascular occlusion of the peripheral circulation can mimic typical Raynaud phenomenon, including peripheral nerve injury,² complex regional pain syndrome,³ occlusive vascular disease, vasculitis, acrocyanosis,⁴ and thoracic outlet syndrome.

The prevalence of Raynaud phenomenon is not exactly known, in part due to geographic differences in climate and variation in methods of assessment. However, a 2015 systematic review and meta-analysis of primary Raynaud phenomenon determined a pooled prevalence of 4.85% (95% confidence interval [CI] 2.08%–8.71%) in the general population.⁵ Accordingly, accurate identification and management of this condition is a useful skill for the internist.

COLD SENSITIVITY AND COLOR CHANGES

Because there are no confirmatory diagnostic tests for this condition, there are no formal diagnostic criteria. However, many experts agree that Raynaud phenomenon can be diagnosed clinically when patients report:

• Unusual sensitivity of the fingers to cold, manifesting as pain or paresthesia (eg, tingling, pricking, numbness), and
• Color changes of the fingers when exposed to cold, specifically pale white or blue-black, or both.⁶

Provocative testing such as submerging patients’ hands in cold water is not recommended, as it is distressing to the patient and inconsistent in triggering an event.

Pain is a symptom of critical digital ischemia.

The skin color changes are due to rapid alterations in blood flow in digital skin. The pale white is due to markedly reduced or absent flow secondary to intense vasoconstriction, the blue-black is due to hypoxemic venous stasis, and the red blush is due to hyperemic reperfusion (Figure 1). However, not all patients have all 3 phases of the classic triphasic color changes, and color changes may not follow a set sequence.

Raynaud phenomenon can also occur in other areas of the body that have thermoregulatory vessels, such as the toes, ears, nipples, tongue, and nose. While some patients with Raynaud phenomenon have a finger that is more sensitive than the others, repeated isolated single-digit or asymmetric events without typical progression to all fingers suggest a secondary local structural disease requiring further investigation (see below).

Symptoms related to Raynaud often mimic sensory changes including paresthesias, numbness, aching, and clumsiness of the hand. Abnormal vascular reactivity has been implicated as a causative factor in several disorders, such as migraine headache, preeclampsia, and variant angina. While case reports, case series, and some controlled studies have linked Raynaud phenomenon and these conditions, there is no solid evidence of a systemic vaso­spastic disorder in patients with primary Raynaud phenomenon.

Raynaud phenomenon is triggered by more than just a cold ambient temperature. Provocation can occur during movement from warmer to relatively cooler temperatures, as well as during episodes of elevated sympathetic activity (eg, emotional distress or fear). In fact, maintaining full body warmth as well as emotional equilibrium are the most important strategies to reduce the frequency of attacks.

PRIMARY VS SECONDARY RAYNAUD PHENOMENON

To distinguish between primary and secondary Raynaud phenomenon, a careful history and physical examination are paramount.

Primary Raynaud phenomenon

In uncomplicated primary Raynaud phenomenon, the episodes typically last 15 to 20 minutes after rewarming and usually start in a single finger and spread to other digits symmetrically and bilaterally.⁷ The thumb is often spared, and ischemic digital ulcers do not occur. Vasoconstrictive episodes are mild.

Females under age 20 are most commonly affected. In our experience, a young woman with the above clinical picture, no signs or symptoms suggestive of connective tissue disease (see below), and normal nailfold capillaries can be diagnosed as having primary Raynaud phenomenon without any further workup.

Careful clinical follow-up is recommended, because if an occult secondary process is indeed present, most patients will begin to show additional symptoms or signs of it within 2 years of the onset of Raynaud phenomenon.

Should a clinician be unfamiliar with nailfold capillary examination, or if symptoms (eg, fatigue or arthralgia) or signs (eg, rash, arthritis) suggestive of connective tissue disease are present, referral to a rheumatologist for further evaluation is appropriate. Results of further diagnostic testing dictated by the history and physical such as a screening antinuclear antibody test can be sent before referral.

Secondary Raynaud phenomenon

Several clinical features suggest secondary Raynaud phenomenon and warrant referral to a rheumatologist:

• Age 20 or older at onset
• Frequent severe vasoconstrictive episodes
• Male sex
• Thumb involvement

• 

  Signs of an autoimmune rheumatic disease, eg, sclerodactyly, cutaneous or mucosal matted telangiectasia, inflammatory arthritis, an abnormal lung examination, severe digital ischemia with ulceration or gangrene, or nailfold capillary dilation or dropout (Figure 2)⁸

  Isolated single-limb or 1-finger ischemic events, seen in macrovascular occlusive disease or inflammatory disease mimicking Raynaud phenomenon (eg, atherosclerosis, vasculitis); when isolated acute ischemic events occur in the upper or lower extremity, a further workup is necessary.

Figure 3 shows our approach to evaluation.

NONPHARMACOLOGIC THERAPY

Cold avoidance and stress management are first-line therapies for preventing Raynaud attacks and must be part of any treatment strategy. Digital arteries and thermoregulatory vessels of the skin are predominantly under sympathetic adrenergic control, so temperature changes and emotional stressors trigger vasoconstriction. Patients should be counseled to:

Keep the whole body warm. Patients should wear multiple layers of clothing, a hat, warm gloves, and warm socks. Commercially available hand-warmers can help, especially for patients who live in cold climates.

Learn to avoid or manage stress. Good communication, attention to the patient’s needs, and regular follow-up for reassurance are paramount. For some patients, psychotropic medications to manage mood may help. Behavioral approaches have been suggested for acute stress management. One approach, autogenic training, is a form of relaxation with temperature biofeedback in which finger temperature data are provided to patients to help them learn to relax by monitoring their internal states and changes in temperature. However, there are no strong data to support the routine use of this technique or the use of one behavioral approach over another. Trials have generally been of low quality and limited by small sample size.⁹

Stop smoking!¹⁰

Stop a Raynaud attack should one occur, eg, place the hands under warm water or in a warm part of the body, such as under legs when sitting. This can help speed recovery.

In addition, the physician should:

Eliminate vasoconstricting agents such as nonselective beta-blockers, ergots, triptans, and amphetamines.

PHARMACOLOGIC THERAPY

For many patients, nonpharmacologic interventions are enough to decrease the severity and frequency of attacks. However, if Raynaud phenomenon continues to negatively affect quality of life, drug therapy can be added (Table 1).

Calcium channel blockers

Calcium channel blockers are first-line agents for both primary and secondary Raynaud phenomenon that does not adequately respond to nonpharmacologic interventions. These agents are effective, available, and reasonably inexpensive. 

Dihydropyridine calcium channel blockers such as nifedipine and amlodipine are commonly used. Both drugs are acceptable options, though some patients may respond better to one than the other in terms of symptoms and side effects. Nondihydropyridines such as diltiazem can also be used, but they have less potent vasodilatory effects because they are less selective for vascular smooth muscle.

These medications should be started at the lowest dose and titrated up over several weeks as tolerated to achieve their maximal effect. Intermittent therapy (eg, during the winter months only) is reasonable for primary Raynaud without risk of digital ulceration, as relief of symptoms and improvement in quality of life are the main indications for therapy in this circumstance.

A 2016 Cochrane review and meta-analysis of the use of calcium channel blockers to treat primary Raynaud phenomenon included 7 randomized controlled trials with 296 patients treated with either nifedipine or nicardipine.¹¹ There was moderate-quality evidence that these drugs minimally decreased the frequency of attacks (standardized mean difference of 0.23; 95% CI 0.08–0.38, P = .003). This translated to 1.72 fewer attacks per week with treatment than with no pharmacologic therapy (95% CI 0.60–2.84). When analyzed individually, only nifedipine was effective; nicardipine did not decrease the frequency of attacks.

Unfortunately, calcium channel blockers failed to decrease the severity of attacks (according to unvalidated severity scoring systems) or make any differences in physiologic measurement outcomes. Attacks were not completely eliminated, just less frequent than before treatment.¹¹

Most commonly reported side effects included headache, flushing, hypotension, edema, and, rarely, gastrointestinal reflux. Use of these medications may be limited by hypotension.

The review was limited by the small sample size, short duration of treatment, and relatively low doses of calcium channel blockers used in the available studies.¹¹

A 2005 meta-analysis also indicated a statistically significant decrease of 2.8 to 5 attacks per week with nifedipine treatment, though this study also included some patients with secondary Raynaud phenomenon.¹²

Phosphodiesterase type 5 inhibitors

When calcium channel blockers do not adequately control symptoms, phosphodiesterase type 5 (PDE5) inhibitors can be added or substituted. These medications work by preventing breakdown of cyclic guanosine monophosphate, which induces relaxation in vascular smooth muscle and vasodilation.

Sildenafil can be started at a low dose (20 mg daily) and up-titrated to the maximum dose (20 mg 3 times daily) as tolerated.

A 2014 meta-analysis of 6 randomized controlled trials included 244 patients with secondary Raynaud phenomenon treated with sildenafil, tadalafil, or vardenafil.¹³ These drugs decreased the daily frequency of attacks by about 0.5 per day vs placebo (–0.49,  95% CI –0.71 to –0.28, P <  .0001). PDE5 inhibitors also decreased the severity of attacks (based on the Raynaud’s Condition Score, a popular scoring system) and the duration of attacks by a statistically significant amount.

Almost all patients in these 6 trials were on PDE5 monotherapy. Data on the cumulative benefit of calcium channel blocker and PDE5 inhibitor combination therapy are not yet available. Not all patients tolerate combination therapy, as it can cause symptomatic hypotension, but it can be a successful option in some.

There are also no data showing that either calcium channel blockers or PDE5 inhibitors are superior, though the former are less expensive. A small double-blind, randomized, crossover study of udenafil vs amlodipine in the treatment of secondary Raynaud phenomenon showed that both medications significantly decreased the frequency of attacks and had comparable efficacy.¹⁴

Cost and insurance coverage. We have generally been successful in obtaining coverage for this off-label use of PDE5 inhibitors, though additional effort may be required. No drug (not even a calcium channel blocker) is approved by the US Food and Drug Administration for use in Raynaud phenomenon. In our experience, a letter of appeal outlining the rationale for use and citing supporting publications can lead to successful coverage of a medication. If the drug is still not approved, the patient either pays for it out of pocket or another agent is selected. In certain circumstances, pharmaceutical companies may provide prescription assistance for compassionate use of these drugs in Raynaud phenomenon, although this also takes letter-writing, phone calls, or both on the part of the physician.

Topical nitrates

Patients who have an unsatisfactory response to calcium channel blockers with or without PDE5 inhibitors can try topical nitrates, available as sustained-release transdermal patches, tapes, creams, gels, and ointments.

Small trials have noted slight improvement in the Raynaud Condition Score¹⁵ and finger temperature¹⁶ with these therapies. Another trial noted decreased frequency of attacks and symptoms with the use of sustained-release glyceryl trinitrate patches, but use was limited by intolerable headache.¹⁷

In our experience, topical nitrates are most helpful for patients who have 1 or a few digits that are more severely affected than the others, and we reserve these drugs for this indication. Localized vasodilation can provide targeted rapid relief of more ischemic areas.

Topical nitroglycerin can be applied to the base of the ischemic digit for 6 to 12 hours. Preparations vary, and patients should be closely monitored for dose response and tolerance.

Combining a topical nitrate with a calcium channel blocker is safe, but the use of a nitrate with a PDE5 inhibitor is contraindicated due to the risk of hypotension. The use of topical nitrates may be limited by systemic side effects such as headache and flushing and a lack of benefit over time.

Other therapies

If the aforementioned agents are not tolerated or not effective, there is limited evidence that other therapies reduce the frequency and sometimes the severity of attacks. These are not first-line agents but may be tried when other options have been exhausted and symptoms persist. There are no data to support combining these therapies, but in our experience doing so may help some patients in whom drug-drug interactions are not prohibitive.

Prazosin, an alpha-1-adrenergic receptor antagonist, was reported to improve Raynaud phenomenon in 2 small studies in the 1980s, but we do not use it since better options are available. In addition, the vasoactive blood vessels involved do not have alpha-1 receptors, so there is no theoretical basis for using prazosin.^18,19

Fluoxetine, a selective serotonin reuptake inhibitor, reduced the frequency and severity of attacks in a 6-week crossover study with nifedipine.²⁰

Losartan, an angiotensin II receptor blocker, also reduced the severity and frequency of attacks when compared with nifedipine.²¹

Pentoxifylline, a nonselective phosphodiesterase inhibitor, showed some benefit in a trial in 11 patients with primary Raynaud.²²

Atorvastatin, a lipid-lowering drug, reduced the number of digital ulcers in patients with secondary Raynaud already on first-line vasodilatory therapy, and might be added in this situation.²³

Botulinum toxin A injections have some data to support their use, but evidence is based on uncontrolled case series.²⁴ A controlled trial in scleroderma patients with severe Raynaud phenomenon found botulinum toxin to be no better than placebo.²⁵

Prostacyclin preparations are available. Intermittent intravenous doses of prostacyclin analogues over several days can be used in resistant cases. Oral prostacyclin agents have not shown consistent benefit. New prostacyclin receptor agonists are under investigation.

Overall, we move to other options only in patients with persistent symptoms that impair quality of life, or in patients with recurrent digital ischemic lesions that have not responded to calcium channel blockers and PDE5 inhibitors or nitrates, either alone or in combination.

DIGITAL ULCERATION AND ACUTE DIGITAL ISCHEMIC CRISIS

Patients with secondary Raynaud phenomenon may be at risk of recurrent digital ulceration and acute digital ischemia with gangrene. These patients should be comanaged with a rheumatologist so that the underlying disease process is fully addressed. Digital ulcers should be inspected closely for signs of infection, which may require treatment with antibiotics.

Acute digital ischemia is a medical emergency and should prompt inpatient admission with warming, emotional regulation, and pain control (often with narcotics) to decrease sympathetic vasoconstriction. These patients require aggressive vasodilatory therapy to reverse the ischemic event.

A short-acting calcium channel blocker or combination therapy with a calcium channel blocker and a PDE5 inhibitor or topical nitrate should be started. If there is no benefit, then transient intravenous vasodilatory therapy with a prostacyclin (epoprostenol) or localized digital sympathectomy is used to prevent digital loss.

The endothelin receptor inhibitor bosentan has been shown to decrease recurrent digital ulcers in patients with scleroderma, and while bosentan does not decrease the frequency of Raynaud attacks, it can be used in this select group to prevent new digital ulcers.

Treatment options may be limited by insurance coverage or access to intravenous infusions.

TAKE-HOME RECOMMENDATIONS

For many patients with primary or secondary Raynaud phenomenon, nonpharmacologic interventions are all that are required to decrease the frequency of attacks and improve quality of life. The goal should not be to eliminate attacks completely, as aggressive drug treatment may cause more harm than benefit. From our perspective, the goals of treatment should be to improve quality of life and prevent ischemic complications.

Pharmacologic therapies should be added only if attacks remain poorly controlled with incapacitating symptoms, or if the patient has digital ischemic ulcers. Calcium channel blockers are first-line therapy, given proven efficacy and low cost, and should be titrated to the maximum tolerated dose before adding or substituting other agents.

Raynaud phenomenon is an overactive vascular response to cold and emotional stress that results in cutaneous color changes and sensory symptoms of the digits (Figure 1). It can occur in isolation as primary Raynaud phenomenon or secondary to another disease process. It is thought to be triggered by a heightened sympathetic vasoconstrictive response of small arteriovenous anastomoses in the fingers, toes, ears, and tip of the nose. These structures play a key role in maintaining a stable core body temperature by cutaneous thermoregulation.¹

Secondary Raynaud phenomenon can be seen with a wide array of systemic conditions as well as environmental and drug exposures. It is a frequent feature of autoimmune rheumatic conditions such as systemic sclerosis, mixed connective tissue disease, systemic lupus erythematosus, and dermatomyositis. Less commonly, cryoproteinemias, paraneoplastic syndromes, hypothyroidism, and carpal tunnel syndrome can be associated with or cause Raynaud phenomenon. Vibratory trauma (eg, from using a jackhammer) and drugs (eg, vasopressors, stimulants, ergots, chemotherapeutic agents) can also cause Raynaud phenomenon.¹

A variety of disorders that cause vasospasm or vascular occlusion of the peripheral circulation can mimic typical Raynaud phenomenon, including peripheral nerve injury,² complex regional pain syndrome,³ occlusive vascular disease, vasculitis, acrocyanosis,⁴ and thoracic outlet syndrome.

The prevalence of Raynaud phenomenon is not exactly known, in part due to geographic differences in climate and variation in methods of assessment. However, a 2015 systematic review and meta-analysis of primary Raynaud phenomenon determined a pooled prevalence of 4.85% (95% confidence interval [CI] 2.08%–8.71%) in the general population.⁵ Accordingly, accurate identification and management of this condition is a useful skill for the internist.

COLD SENSITIVITY AND COLOR CHANGES

Because there are no confirmatory diagnostic tests for this condition, there are no formal diagnostic criteria. However, many experts agree that Raynaud phenomenon can be diagnosed clinically when patients report:

• Unusual sensitivity of the fingers to cold, manifesting as pain or paresthesia (eg, tingling, pricking, numbness), and
• Color changes of the fingers when exposed to cold, specifically pale white or blue-black, or both.⁶

Provocative testing such as submerging patients’ hands in cold water is not recommended, as it is distressing to the patient and inconsistent in triggering an event.

Pain is a symptom of critical digital ischemia.

The skin color changes are due to rapid alterations in blood flow in digital skin. The pale white is due to markedly reduced or absent flow secondary to intense vasoconstriction, the blue-black is due to hypoxemic venous stasis, and the red blush is due to hyperemic reperfusion (Figure 1). However, not all patients have all 3 phases of the classic triphasic color changes, and color changes may not follow a set sequence.

Raynaud phenomenon can also occur in other areas of the body that have thermoregulatory vessels, such as the toes, ears, nipples, tongue, and nose. While some patients with Raynaud phenomenon have a finger that is more sensitive than the others, repeated isolated single-digit or asymmetric events without typical progression to all fingers suggest a secondary local structural disease requiring further investigation (see below).

Symptoms related to Raynaud often mimic sensory changes including paresthesias, numbness, aching, and clumsiness of the hand. Abnormal vascular reactivity has been implicated as a causative factor in several disorders, such as migraine headache, preeclampsia, and variant angina. While case reports, case series, and some controlled studies have linked Raynaud phenomenon and these conditions, there is no solid evidence of a systemic vaso­spastic disorder in patients with primary Raynaud phenomenon.

Raynaud phenomenon is triggered by more than just a cold ambient temperature. Provocation can occur during movement from warmer to relatively cooler temperatures, as well as during episodes of elevated sympathetic activity (eg, emotional distress or fear). In fact, maintaining full body warmth as well as emotional equilibrium are the most important strategies to reduce the frequency of attacks.

PRIMARY VS SECONDARY RAYNAUD PHENOMENON

To distinguish between primary and secondary Raynaud phenomenon, a careful history and physical examination are paramount.

Primary Raynaud phenomenon

In uncomplicated primary Raynaud phenomenon, the episodes typically last 15 to 20 minutes after rewarming and usually start in a single finger and spread to other digits symmetrically and bilaterally.⁷ The thumb is often spared, and ischemic digital ulcers do not occur. Vasoconstrictive episodes are mild.

Females under age 20 are most commonly affected. In our experience, a young woman with the above clinical picture, no signs or symptoms suggestive of connective tissue disease (see below), and normal nailfold capillaries can be diagnosed as having primary Raynaud phenomenon without any further workup.

Careful clinical follow-up is recommended, because if an occult secondary process is indeed present, most patients will begin to show additional symptoms or signs of it within 2 years of the onset of Raynaud phenomenon.

Should a clinician be unfamiliar with nailfold capillary examination, or if symptoms (eg, fatigue or arthralgia) or signs (eg, rash, arthritis) suggestive of connective tissue disease are present, referral to a rheumatologist for further evaluation is appropriate. Results of further diagnostic testing dictated by the history and physical such as a screening antinuclear antibody test can be sent before referral.

Secondary Raynaud phenomenon

Several clinical features suggest secondary Raynaud phenomenon and warrant referral to a rheumatologist:

• Age 20 or older at onset
• Frequent severe vasoconstrictive episodes
• Male sex
• Thumb involvement

• 

  Signs of an autoimmune rheumatic disease, eg, sclerodactyly, cutaneous or mucosal matted telangiectasia, inflammatory arthritis, an abnormal lung examination, severe digital ischemia with ulceration or gangrene, or nailfold capillary dilation or dropout (Figure 2)⁸

  Isolated single-limb or 1-finger ischemic events, seen in macrovascular occlusive disease or inflammatory disease mimicking Raynaud phenomenon (eg, atherosclerosis, vasculitis); when isolated acute ischemic events occur in the upper or lower extremity, a further workup is necessary.

Figure 3 shows our approach to evaluation.

NONPHARMACOLOGIC THERAPY

Cold avoidance and stress management are first-line therapies for preventing Raynaud attacks and must be part of any treatment strategy. Digital arteries and thermoregulatory vessels of the skin are predominantly under sympathetic adrenergic control, so temperature changes and emotional stressors trigger vasoconstriction. Patients should be counseled to:

Keep the whole body warm. Patients should wear multiple layers of clothing, a hat, warm gloves, and warm socks. Commercially available hand-warmers can help, especially for patients who live in cold climates.

Learn to avoid or manage stress. Good communication, attention to the patient’s needs, and regular follow-up for reassurance are paramount. For some patients, psychotropic medications to manage mood may help. Behavioral approaches have been suggested for acute stress management. One approach, autogenic training, is a form of relaxation with temperature biofeedback in which finger temperature data are provided to patients to help them learn to relax by monitoring their internal states and changes in temperature. However, there are no strong data to support the routine use of this technique or the use of one behavioral approach over another. Trials have generally been of low quality and limited by small sample size.⁹

Stop smoking!¹⁰

Stop a Raynaud attack should one occur, eg, place the hands under warm water or in a warm part of the body, such as under legs when sitting. This can help speed recovery.

In addition, the physician should:

Eliminate vasoconstricting agents such as nonselective beta-blockers, ergots, triptans, and amphetamines.

PHARMACOLOGIC THERAPY

For many patients, nonpharmacologic interventions are enough to decrease the severity and frequency of attacks. However, if Raynaud phenomenon continues to negatively affect quality of life, drug therapy can be added (Table 1).

Calcium channel blockers

Calcium channel blockers are first-line agents for both primary and secondary Raynaud phenomenon that does not adequately respond to nonpharmacologic interventions. These agents are effective, available, and reasonably inexpensive. 

Dihydropyridine calcium channel blockers such as nifedipine and amlodipine are commonly used. Both drugs are acceptable options, though some patients may respond better to one than the other in terms of symptoms and side effects. Nondihydropyridines such as diltiazem can also be used, but they have less potent vasodilatory effects because they are less selective for vascular smooth muscle.

These medications should be started at the lowest dose and titrated up over several weeks as tolerated to achieve their maximal effect. Intermittent therapy (eg, during the winter months only) is reasonable for primary Raynaud without risk of digital ulceration, as relief of symptoms and improvement in quality of life are the main indications for therapy in this circumstance.

A 2016 Cochrane review and meta-analysis of the use of calcium channel blockers to treat primary Raynaud phenomenon included 7 randomized controlled trials with 296 patients treated with either nifedipine or nicardipine.¹¹ There was moderate-quality evidence that these drugs minimally decreased the frequency of attacks (standardized mean difference of 0.23; 95% CI 0.08–0.38, P = .003). This translated to 1.72 fewer attacks per week with treatment than with no pharmacologic therapy (95% CI 0.60–2.84). When analyzed individually, only nifedipine was effective; nicardipine did not decrease the frequency of attacks.

Unfortunately, calcium channel blockers failed to decrease the severity of attacks (according to unvalidated severity scoring systems) or make any differences in physiologic measurement outcomes. Attacks were not completely eliminated, just less frequent than before treatment.¹¹

Most commonly reported side effects included headache, flushing, hypotension, edema, and, rarely, gastrointestinal reflux. Use of these medications may be limited by hypotension.

The review was limited by the small sample size, short duration of treatment, and relatively low doses of calcium channel blockers used in the available studies.¹¹

A 2005 meta-analysis also indicated a statistically significant decrease of 2.8 to 5 attacks per week with nifedipine treatment, though this study also included some patients with secondary Raynaud phenomenon.¹²

Phosphodiesterase type 5 inhibitors

When calcium channel blockers do not adequately control symptoms, phosphodiesterase type 5 (PDE5) inhibitors can be added or substituted. These medications work by preventing breakdown of cyclic guanosine monophosphate, which induces relaxation in vascular smooth muscle and vasodilation.

Sildenafil can be started at a low dose (20 mg daily) and up-titrated to the maximum dose (20 mg 3 times daily) as tolerated.

A 2014 meta-analysis of 6 randomized controlled trials included 244 patients with secondary Raynaud phenomenon treated with sildenafil, tadalafil, or vardenafil.¹³ These drugs decreased the daily frequency of attacks by about 0.5 per day vs placebo (–0.49,  95% CI –0.71 to –0.28, P <  .0001). PDE5 inhibitors also decreased the severity of attacks (based on the Raynaud’s Condition Score, a popular scoring system) and the duration of attacks by a statistically significant amount.

Almost all patients in these 6 trials were on PDE5 monotherapy. Data on the cumulative benefit of calcium channel blocker and PDE5 inhibitor combination therapy are not yet available. Not all patients tolerate combination therapy, as it can cause symptomatic hypotension, but it can be a successful option in some.

There are also no data showing that either calcium channel blockers or PDE5 inhibitors are superior, though the former are less expensive. A small double-blind, randomized, crossover study of udenafil vs amlodipine in the treatment of secondary Raynaud phenomenon showed that both medications significantly decreased the frequency of attacks and had comparable efficacy.¹⁴

Cost and insurance coverage. We have generally been successful in obtaining coverage for this off-label use of PDE5 inhibitors, though additional effort may be required. No drug (not even a calcium channel blocker) is approved by the US Food and Drug Administration for use in Raynaud phenomenon. In our experience, a letter of appeal outlining the rationale for use and citing supporting publications can lead to successful coverage of a medication. If the drug is still not approved, the patient either pays for it out of pocket or another agent is selected. In certain circumstances, pharmaceutical companies may provide prescription assistance for compassionate use of these drugs in Raynaud phenomenon, although this also takes letter-writing, phone calls, or both on the part of the physician.

Topical nitrates

Patients who have an unsatisfactory response to calcium channel blockers with or without PDE5 inhibitors can try topical nitrates, available as sustained-release transdermal patches, tapes, creams, gels, and ointments.

Small trials have noted slight improvement in the Raynaud Condition Score¹⁵ and finger temperature¹⁶ with these therapies. Another trial noted decreased frequency of attacks and symptoms with the use of sustained-release glyceryl trinitrate patches, but use was limited by intolerable headache.¹⁷

In our experience, topical nitrates are most helpful for patients who have 1 or a few digits that are more severely affected than the others, and we reserve these drugs for this indication. Localized vasodilation can provide targeted rapid relief of more ischemic areas.

Topical nitroglycerin can be applied to the base of the ischemic digit for 6 to 12 hours. Preparations vary, and patients should be closely monitored for dose response and tolerance.

Combining a topical nitrate with a calcium channel blocker is safe, but the use of a nitrate with a PDE5 inhibitor is contraindicated due to the risk of hypotension. The use of topical nitrates may be limited by systemic side effects such as headache and flushing and a lack of benefit over time.

Other therapies

If the aforementioned agents are not tolerated or not effective, there is limited evidence that other therapies reduce the frequency and sometimes the severity of attacks. These are not first-line agents but may be tried when other options have been exhausted and symptoms persist. There are no data to support combining these therapies, but in our experience doing so may help some patients in whom drug-drug interactions are not prohibitive.

Prazosin, an alpha-1-adrenergic receptor antagonist, was reported to improve Raynaud phenomenon in 2 small studies in the 1980s, but we do not use it since better options are available. In addition, the vasoactive blood vessels involved do not have alpha-1 receptors, so there is no theoretical basis for using prazosin.^18,19

Fluoxetine, a selective serotonin reuptake inhibitor, reduced the frequency and severity of attacks in a 6-week crossover study with nifedipine.²⁰

Losartan, an angiotensin II receptor blocker, also reduced the severity and frequency of attacks when compared with nifedipine.²¹

Pentoxifylline, a nonselective phosphodiesterase inhibitor, showed some benefit in a trial in 11 patients with primary Raynaud.²²

Atorvastatin, a lipid-lowering drug, reduced the number of digital ulcers in patients with secondary Raynaud already on first-line vasodilatory therapy, and might be added in this situation.²³

Botulinum toxin A injections have some data to support their use, but evidence is based on uncontrolled case series.²⁴ A controlled trial in scleroderma patients with severe Raynaud phenomenon found botulinum toxin to be no better than placebo.²⁵

Prostacyclin preparations are available. Intermittent intravenous doses of prostacyclin analogues over several days can be used in resistant cases. Oral prostacyclin agents have not shown consistent benefit. New prostacyclin receptor agonists are under investigation.

Overall, we move to other options only in patients with persistent symptoms that impair quality of life, or in patients with recurrent digital ischemic lesions that have not responded to calcium channel blockers and PDE5 inhibitors or nitrates, either alone or in combination.

DIGITAL ULCERATION AND ACUTE DIGITAL ISCHEMIC CRISIS

Patients with secondary Raynaud phenomenon may be at risk of recurrent digital ulceration and acute digital ischemia with gangrene. These patients should be comanaged with a rheumatologist so that the underlying disease process is fully addressed. Digital ulcers should be inspected closely for signs of infection, which may require treatment with antibiotics.

Acute digital ischemia is a medical emergency and should prompt inpatient admission with warming, emotional regulation, and pain control (often with narcotics) to decrease sympathetic vasoconstriction. These patients require aggressive vasodilatory therapy to reverse the ischemic event.

A short-acting calcium channel blocker or combination therapy with a calcium channel blocker and a PDE5 inhibitor or topical nitrate should be started. If there is no benefit, then transient intravenous vasodilatory therapy with a prostacyclin (epoprostenol) or localized digital sympathectomy is used to prevent digital loss.

The endothelin receptor inhibitor bosentan has been shown to decrease recurrent digital ulcers in patients with scleroderma, and while bosentan does not decrease the frequency of Raynaud attacks, it can be used in this select group to prevent new digital ulcers.

Treatment options may be limited by insurance coverage or access to intravenous infusions.

TAKE-HOME RECOMMENDATIONS

For many patients with primary or secondary Raynaud phenomenon, nonpharmacologic interventions are all that are required to decrease the frequency of attacks and improve quality of life. The goal should not be to eliminate attacks completely, as aggressive drug treatment may cause more harm than benefit. From our perspective, the goals of treatment should be to improve quality of life and prevent ischemic complications.

Pharmacologic therapies should be added only if attacks remain poorly controlled with incapacitating symptoms, or if the patient has digital ischemic ulcers. Calcium channel blockers are first-line therapy, given proven efficacy and low cost, and should be titrated to the maximum tolerated dose before adding or substituting other agents.

Raynaud phenomenon is an overactive vascular response to cold and emotional stress that results in cutaneous color changes and sensory symptoms of the digits (Figure 1). It can occur in isolation as primary Raynaud phenomenon or secondary to another disease process. It is thought to be triggered by a heightened sympathetic vasoconstrictive response of small arteriovenous anastomoses in the fingers, toes, ears, and tip of the nose. These structures play a key role in maintaining a stable core body temperature by cutaneous thermoregulation.¹

Secondary Raynaud phenomenon can be seen with a wide array of systemic conditions as well as environmental and drug exposures. It is a frequent feature of autoimmune rheumatic conditions such as systemic sclerosis, mixed connective tissue disease, systemic lupus erythematosus, and dermatomyositis. Less commonly, cryoproteinemias, paraneoplastic syndromes, hypothyroidism, and carpal tunnel syndrome can be associated with or cause Raynaud phenomenon. Vibratory trauma (eg, from using a jackhammer) and drugs (eg, vasopressors, stimulants, ergots, chemotherapeutic agents) can also cause Raynaud phenomenon.¹

A variety of disorders that cause vasospasm or vascular occlusion of the peripheral circulation can mimic typical Raynaud phenomenon, including peripheral nerve injury,² complex regional pain syndrome,³ occlusive vascular disease, vasculitis, acrocyanosis,⁴ and thoracic outlet syndrome.

The prevalence of Raynaud phenomenon is not exactly known, in part due to geographic differences in climate and variation in methods of assessment. However, a 2015 systematic review and meta-analysis of primary Raynaud phenomenon determined a pooled prevalence of 4.85% (95% confidence interval [CI] 2.08%–8.71%) in the general population.⁵ Accordingly, accurate identification and management of this condition is a useful skill for the internist.

COLD SENSITIVITY AND COLOR CHANGES

Because there are no confirmatory diagnostic tests for this condition, there are no formal diagnostic criteria. However, many experts agree that Raynaud phenomenon can be diagnosed clinically when patients report:

• Unusual sensitivity of the fingers to cold, manifesting as pain or paresthesia (eg, tingling, pricking, numbness), and
• Color changes of the fingers when exposed to cold, specifically pale white or blue-black, or both.⁶

Provocative testing such as submerging patients’ hands in cold water is not recommended, as it is distressing to the patient and inconsistent in triggering an event.

Pain is a symptom of critical digital ischemia.

The skin color changes are due to rapid alterations in blood flow in digital skin. The pale white is due to markedly reduced or absent flow secondary to intense vasoconstriction, the blue-black is due to hypoxemic venous stasis, and the red blush is due to hyperemic reperfusion (Figure 1). However, not all patients have all 3 phases of the classic triphasic color changes, and color changes may not follow a set sequence.

Raynaud phenomenon can also occur in other areas of the body that have thermoregulatory vessels, such as the toes, ears, nipples, tongue, and nose. While some patients with Raynaud phenomenon have a finger that is more sensitive than the others, repeated isolated single-digit or asymmetric events without typical progression to all fingers suggest a secondary local structural disease requiring further investigation (see below).

Symptoms related to Raynaud often mimic sensory changes including paresthesias, numbness, aching, and clumsiness of the hand. Abnormal vascular reactivity has been implicated as a causative factor in several disorders, such as migraine headache, preeclampsia, and variant angina. While case reports, case series, and some controlled studies have linked Raynaud phenomenon and these conditions, there is no solid evidence of a systemic vaso­spastic disorder in patients with primary Raynaud phenomenon.

Raynaud phenomenon is triggered by more than just a cold ambient temperature. Provocation can occur during movement from warmer to relatively cooler temperatures, as well as during episodes of elevated sympathetic activity (eg, emotional distress or fear). In fact, maintaining full body warmth as well as emotional equilibrium are the most important strategies to reduce the frequency of attacks.

PRIMARY VS SECONDARY RAYNAUD PHENOMENON

To distinguish between primary and secondary Raynaud phenomenon, a careful history and physical examination are paramount.

Primary Raynaud phenomenon

In uncomplicated primary Raynaud phenomenon, the episodes typically last 15 to 20 minutes after rewarming and usually start in a single finger and spread to other digits symmetrically and bilaterally.⁷ The thumb is often spared, and ischemic digital ulcers do not occur. Vasoconstrictive episodes are mild.

Females under age 20 are most commonly affected. In our experience, a young woman with the above clinical picture, no signs or symptoms suggestive of connective tissue disease (see below), and normal nailfold capillaries can be diagnosed as having primary Raynaud phenomenon without any further workup.

Careful clinical follow-up is recommended, because if an occult secondary process is indeed present, most patients will begin to show additional symptoms or signs of it within 2 years of the onset of Raynaud phenomenon.

Should a clinician be unfamiliar with nailfold capillary examination, or if symptoms (eg, fatigue or arthralgia) or signs (eg, rash, arthritis) suggestive of connective tissue disease are present, referral to a rheumatologist for further evaluation is appropriate. Results of further diagnostic testing dictated by the history and physical such as a screening antinuclear antibody test can be sent before referral.

Secondary Raynaud phenomenon

Several clinical features suggest secondary Raynaud phenomenon and warrant referral to a rheumatologist:

• Age 20 or older at onset
• Frequent severe vasoconstrictive episodes
• Male sex
• Thumb involvement

• 

  Signs of an autoimmune rheumatic disease, eg, sclerodactyly, cutaneous or mucosal matted telangiectasia, inflammatory arthritis, an abnormal lung examination, severe digital ischemia with ulceration or gangrene, or nailfold capillary dilation or dropout (Figure 2)⁸

  Isolated single-limb or 1-finger ischemic events, seen in macrovascular occlusive disease or inflammatory disease mimicking Raynaud phenomenon (eg, atherosclerosis, vasculitis); when isolated acute ischemic events occur in the upper or lower extremity, a further workup is necessary.

Figure 3 shows our approach to evaluation.

NONPHARMACOLOGIC THERAPY

Cold avoidance and stress management are first-line therapies for preventing Raynaud attacks and must be part of any treatment strategy. Digital arteries and thermoregulatory vessels of the skin are predominantly under sympathetic adrenergic control, so temperature changes and emotional stressors trigger vasoconstriction. Patients should be counseled to:

Keep the whole body warm. Patients should wear multiple layers of clothing, a hat, warm gloves, and warm socks. Commercially available hand-warmers can help, especially for patients who live in cold climates.

Learn to avoid or manage stress. Good communication, attention to the patient’s needs, and regular follow-up for reassurance are paramount. For some patients, psychotropic medications to manage mood may help. Behavioral approaches have been suggested for acute stress management. One approach, autogenic training, is a form of relaxation with temperature biofeedback in which finger temperature data are provided to patients to help them learn to relax by monitoring their internal states and changes in temperature. However, there are no strong data to support the routine use of this technique or the use of one behavioral approach over another. Trials have generally been of low quality and limited by small sample size.⁹

Stop smoking!¹⁰

Stop a Raynaud attack should one occur, eg, place the hands under warm water or in a warm part of the body, such as under legs when sitting. This can help speed recovery.

In addition, the physician should:

Eliminate vasoconstricting agents such as nonselective beta-blockers, ergots, triptans, and amphetamines.

PHARMACOLOGIC THERAPY

For many patients, nonpharmacologic interventions are enough to decrease the severity and frequency of attacks. However, if Raynaud phenomenon continues to negatively affect quality of life, drug therapy can be added (Table 1).

Calcium channel blockers

Calcium channel blockers are first-line agents for both primary and secondary Raynaud phenomenon that does not adequately respond to nonpharmacologic interventions. These agents are effective, available, and reasonably inexpensive. 

Dihydropyridine calcium channel blockers such as nifedipine and amlodipine are commonly used. Both drugs are acceptable options, though some patients may respond better to one than the other in terms of symptoms and side effects. Nondihydropyridines such as diltiazem can also be used, but they have less potent vasodilatory effects because they are less selective for vascular smooth muscle.

These medications should be started at the lowest dose and titrated up over several weeks as tolerated to achieve their maximal effect. Intermittent therapy (eg, during the winter months only) is reasonable for primary Raynaud without risk of digital ulceration, as relief of symptoms and improvement in quality of life are the main indications for therapy in this circumstance.

A 2016 Cochrane review and meta-analysis of the use of calcium channel blockers to treat primary Raynaud phenomenon included 7 randomized controlled trials with 296 patients treated with either nifedipine or nicardipine.¹¹ There was moderate-quality evidence that these drugs minimally decreased the frequency of attacks (standardized mean difference of 0.23; 95% CI 0.08–0.38, P = .003). This translated to 1.72 fewer attacks per week with treatment than with no pharmacologic therapy (95% CI 0.60–2.84). When analyzed individually, only nifedipine was effective; nicardipine did not decrease the frequency of attacks.

Unfortunately, calcium channel blockers failed to decrease the severity of attacks (according to unvalidated severity scoring systems) or make any differences in physiologic measurement outcomes. Attacks were not completely eliminated, just less frequent than before treatment.¹¹

Most commonly reported side effects included headache, flushing, hypotension, edema, and, rarely, gastrointestinal reflux. Use of these medications may be limited by hypotension.

The review was limited by the small sample size, short duration of treatment, and relatively low doses of calcium channel blockers used in the available studies.¹¹

A 2005 meta-analysis also indicated a statistically significant decrease of 2.8 to 5 attacks per week with nifedipine treatment, though this study also included some patients with secondary Raynaud phenomenon.¹²

Phosphodiesterase type 5 inhibitors

When calcium channel blockers do not adequately control symptoms, phosphodiesterase type 5 (PDE5) inhibitors can be added or substituted. These medications work by preventing breakdown of cyclic guanosine monophosphate, which induces relaxation in vascular smooth muscle and vasodilation.

Sildenafil can be started at a low dose (20 mg daily) and up-titrated to the maximum dose (20 mg 3 times daily) as tolerated.

A 2014 meta-analysis of 6 randomized controlled trials included 244 patients with secondary Raynaud phenomenon treated with sildenafil, tadalafil, or vardenafil.¹³ These drugs decreased the daily frequency of attacks by about 0.5 per day vs placebo (–0.49,  95% CI –0.71 to –0.28, P <  .0001). PDE5 inhibitors also decreased the severity of attacks (based on the Raynaud’s Condition Score, a popular scoring system) and the duration of attacks by a statistically significant amount.

Almost all patients in these 6 trials were on PDE5 monotherapy. Data on the cumulative benefit of calcium channel blocker and PDE5 inhibitor combination therapy are not yet available. Not all patients tolerate combination therapy, as it can cause symptomatic hypotension, but it can be a successful option in some.

There are also no data showing that either calcium channel blockers or PDE5 inhibitors are superior, though the former are less expensive. A small double-blind, randomized, crossover study of udenafil vs amlodipine in the treatment of secondary Raynaud phenomenon showed that both medications significantly decreased the frequency of attacks and had comparable efficacy.¹⁴

Cost and insurance coverage. We have generally been successful in obtaining coverage for this off-label use of PDE5 inhibitors, though additional effort may be required. No drug (not even a calcium channel blocker) is approved by the US Food and Drug Administration for use in Raynaud phenomenon. In our experience, a letter of appeal outlining the rationale for use and citing supporting publications can lead to successful coverage of a medication. If the drug is still not approved, the patient either pays for it out of pocket or another agent is selected. In certain circumstances, pharmaceutical companies may provide prescription assistance for compassionate use of these drugs in Raynaud phenomenon, although this also takes letter-writing, phone calls, or both on the part of the physician.

Topical nitrates

Patients who have an unsatisfactory response to calcium channel blockers with or without PDE5 inhibitors can try topical nitrates, available as sustained-release transdermal patches, tapes, creams, gels, and ointments.

Small trials have noted slight improvement in the Raynaud Condition Score¹⁵ and finger temperature¹⁶ with these therapies. Another trial noted decreased frequency of attacks and symptoms with the use of sustained-release glyceryl trinitrate patches, but use was limited by intolerable headache.¹⁷

In our experience, topical nitrates are most helpful for patients who have 1 or a few digits that are more severely affected than the others, and we reserve these drugs for this indication. Localized vasodilation can provide targeted rapid relief of more ischemic areas.

Topical nitroglycerin can be applied to the base of the ischemic digit for 6 to 12 hours. Preparations vary, and patients should be closely monitored for dose response and tolerance.

Combining a topical nitrate with a calcium channel blocker is safe, but the use of a nitrate with a PDE5 inhibitor is contraindicated due to the risk of hypotension. The use of topical nitrates may be limited by systemic side effects such as headache and flushing and a lack of benefit over time.

Other therapies

If the aforementioned agents are not tolerated or not effective, there is limited evidence that other therapies reduce the frequency and sometimes the severity of attacks. These are not first-line agents but may be tried when other options have been exhausted and symptoms persist. There are no data to support combining these therapies, but in our experience doing so may help some patients in whom drug-drug interactions are not prohibitive.

Prazosin, an alpha-1-adrenergic receptor antagonist, was reported to improve Raynaud phenomenon in 2 small studies in the 1980s, but we do not use it since better options are available. In addition, the vasoactive blood vessels involved do not have alpha-1 receptors, so there is no theoretical basis for using prazosin.^18,19

Fluoxetine, a selective serotonin reuptake inhibitor, reduced the frequency and severity of attacks in a 6-week crossover study with nifedipine.²⁰

Losartan, an angiotensin II receptor blocker, also reduced the severity and frequency of attacks when compared with nifedipine.²¹

Pentoxifylline, a nonselective phosphodiesterase inhibitor, showed some benefit in a trial in 11 patients with primary Raynaud.²²

Atorvastatin, a lipid-lowering drug, reduced the number of digital ulcers in patients with secondary Raynaud already on first-line vasodilatory therapy, and might be added in this situation.²³

Botulinum toxin A injections have some data to support their use, but evidence is based on uncontrolled case series.²⁴ A controlled trial in scleroderma patients with severe Raynaud phenomenon found botulinum toxin to be no better than placebo.²⁵

Prostacyclin preparations are available. Intermittent intravenous doses of prostacyclin analogues over several days can be used in resistant cases. Oral prostacyclin agents have not shown consistent benefit. New prostacyclin receptor agonists are under investigation.

Overall, we move to other options only in patients with persistent symptoms that impair quality of life, or in patients with recurrent digital ischemic lesions that have not responded to calcium channel blockers and PDE5 inhibitors or nitrates, either alone or in combination.

DIGITAL ULCERATION AND ACUTE DIGITAL ISCHEMIC CRISIS

Patients with secondary Raynaud phenomenon may be at risk of recurrent digital ulceration and acute digital ischemia with gangrene. These patients should be comanaged with a rheumatologist so that the underlying disease process is fully addressed. Digital ulcers should be inspected closely for signs of infection, which may require treatment with antibiotics.

Acute digital ischemia is a medical emergency and should prompt inpatient admission with warming, emotional regulation, and pain control (often with narcotics) to decrease sympathetic vasoconstriction. These patients require aggressive vasodilatory therapy to reverse the ischemic event.

A short-acting calcium channel blocker or combination therapy with a calcium channel blocker and a PDE5 inhibitor or topical nitrate should be started. If there is no benefit, then transient intravenous vasodilatory therapy with a prostacyclin (epoprostenol) or localized digital sympathectomy is used to prevent digital loss.

The endothelin receptor inhibitor bosentan has been shown to decrease recurrent digital ulcers in patients with scleroderma, and while bosentan does not decrease the frequency of Raynaud attacks, it can be used in this select group to prevent new digital ulcers.

Treatment options may be limited by insurance coverage or access to intravenous infusions.

TAKE-HOME RECOMMENDATIONS

For many patients with primary or secondary Raynaud phenomenon, nonpharmacologic interventions are all that are required to decrease the frequency of attacks and improve quality of life. The goal should not be to eliminate attacks completely, as aggressive drug treatment may cause more harm than benefit. From our perspective, the goals of treatment should be to improve quality of life and prevent ischemic complications.

Pharmacologic therapies should be added only if attacks remain poorly controlled with incapacitating symptoms, or if the patient has digital ischemic ulcers. Calcium channel blockers are first-line therapy, given proven efficacy and low cost, and should be titrated to the maximum tolerated dose before adding or substituting other agents.

For many patients, Raynaud symptoms are mild enough to not even mention to their primary care provider, and conversely, there is little reason for most clinicians to routinely inquire about such symptoms. So it may surprise some readers to read about the nuances of diagnosis and treatment discussed by Shapiro and Wigley in this issue of the Journal.

To a rheumatologist, Raynaud phenomenon, particularly of recent onset in an adult, raises the specter of an underlying systemic inflammatory disease. The phenomenon is not linked to a specific diagnosis; it is associated with lupus, rheumatoid arthritis, cryoglobulinemia, inflammatory myopathy, Sjögren syndrome, and, in its severe form, with the scleroderma syndromes. We focus on differentiating between these rheumatic disorders once we have discarded nonrheumatic causes such as atherosclerotic arterial disease, carcinoma, embolism, Buerger disease, medications, smoking, or thrombosis.

But rheumatologists are toward the bottom of the diagnostic funnel—we see these patients when an underlying disease is already suspected. The real challenge is for the primary care providers who first recognize the digital vasospasm on examination or are told of the symptoms by their patient. These clinicians need to know which initial reflexive actions are warranted and which can wait, for, as noted by Shapiro and Wigley, there are several options.

The first action is to try to determine the timeline, although Raynaud disease often has an insidious onset or the patient doesn’t recall the onset. New and sudden onset likely has a stronger association with an underlying disease. A focused physical examination should look for digital stigmata of ischemic damage; the presence of digital ulcers or healed digital pits indicates a possible vascular occlusive component in addition to the vascular spasm. This strongly suggests scleroderma or Buerger disease, as tissue damage doesn’t occur in (primary) Raynaud disease or generally even with Raynaud phenomenon associated with lupus or other rheumatic disorders. Sclerodactyly should be looked for: diffuse finger puffiness, skin-tightening, or early signs such as loss of the usual finger skin creases. Telangiectasia (not vascular spiders or cherry angiomata) should be searched for, particularly on the palms, face, and inner lips, as these vascular lesions are common in patients with limited scleroderma. Careful auscultation for basilar lung crackles should be done. Distal pulses should all be assessed, and bruits in the neck, abdomen and inguinal areas should be carefully sought.

Patients should be questioned about any symptom-associated reduction in exercise tolerance and particularly about trouble swallowing, “heartburn,” and symptoms of reflux. Although patients with Raynaud disease may have demonstrable esophageal dysmotility, the presence of significant, new, or worsened symptoms raises the concern of scleroderma. Patients should be asked about symptoms of malabsorption. Specific questioning should be directed at eliciting a history of joint stiffness and especially muscle weakness. The latter can be approached by inquiring about new or progressive difficulty in specific tasks such as walking up steps, brushing hair, and arising from low chairs or the toilet. Distinguishing muscle weakness from general fatigue is not always easy, but it is important.

Shapiro and Wigley discuss the extremely useful evaluation of nailfold capillaries, which can be done with a standard magnifier or ophthalmoscope. This is very valuable to help predict the development or current presence of a systemic rheumatic disease. But this is not a technique that most clinicians are familiar with. A potentially useful surrogate or adjunctive test, especially in the setting of new-onset Raynaud, is the antinuclear antibody (ANA) test; I prefer the immunofluorescent assay. While a positive test alone (with Raynaud) does not define the presence of any rheumatic disease, several older studies suggest that patients with a new onset of Raynaud phenomenon and a positive ANA test are more likely to develop a systemic autoimmune disorder than if the test is negative. Those who do so (and this is far from all) are most likely to have the disease manifest within a few years. Hence, if the ANA test is positive but the history, physical examination, and limited laboratory testing (complete blood cell count with differential, complete metabolic panel, creatine kinase, and urinalysis) are normal, it is reasonable to reexamine the patient in 3 months and then every 6 months for 2 to 3 years, repeating the focused history and physical examination. It is also reasonable at some point to refer these patients to a rheumatologist.

Since Raynaud phenomenon is common, and the associated severe rheumatic disorders associated with it are rare, it is easy to not recognize Raynaud phenomenon as a clue to the onset of a potentially severe systemic disease. Yet with a few simple questions, a focused examination, and minimal laboratory testing, patients who are more likely to harbor a systemic disease can usually be treated symptomatically if necessary, and appropriately triaged to observation or for subspecialty referral.

For many patients, Raynaud symptoms are mild enough to not even mention to their primary care provider, and conversely, there is little reason for most clinicians to routinely inquire about such symptoms. So it may surprise some readers to read about the nuances of diagnosis and treatment discussed by Shapiro and Wigley in this issue of the Journal.

To a rheumatologist, Raynaud phenomenon, particularly of recent onset in an adult, raises the specter of an underlying systemic inflammatory disease. The phenomenon is not linked to a specific diagnosis; it is associated with lupus, rheumatoid arthritis, cryoglobulinemia, inflammatory myopathy, Sjögren syndrome, and, in its severe form, with the scleroderma syndromes. We focus on differentiating between these rheumatic disorders once we have discarded nonrheumatic causes such as atherosclerotic arterial disease, carcinoma, embolism, Buerger disease, medications, smoking, or thrombosis.

But rheumatologists are toward the bottom of the diagnostic funnel—we see these patients when an underlying disease is already suspected. The real challenge is for the primary care providers who first recognize the digital vasospasm on examination or are told of the symptoms by their patient. These clinicians need to know which initial reflexive actions are warranted and which can wait, for, as noted by Shapiro and Wigley, there are several options.

The first action is to try to determine the timeline, although Raynaud disease often has an insidious onset or the patient doesn’t recall the onset. New and sudden onset likely has a stronger association with an underlying disease. A focused physical examination should look for digital stigmata of ischemic damage; the presence of digital ulcers or healed digital pits indicates a possible vascular occlusive component in addition to the vascular spasm. This strongly suggests scleroderma or Buerger disease, as tissue damage doesn’t occur in (primary) Raynaud disease or generally even with Raynaud phenomenon associated with lupus or other rheumatic disorders. Sclerodactyly should be looked for: diffuse finger puffiness, skin-tightening, or early signs such as loss of the usual finger skin creases. Telangiectasia (not vascular spiders or cherry angiomata) should be searched for, particularly on the palms, face, and inner lips, as these vascular lesions are common in patients with limited scleroderma. Careful auscultation for basilar lung crackles should be done. Distal pulses should all be assessed, and bruits in the neck, abdomen and inguinal areas should be carefully sought.

Patients should be questioned about any symptom-associated reduction in exercise tolerance and particularly about trouble swallowing, “heartburn,” and symptoms of reflux. Although patients with Raynaud disease may have demonstrable esophageal dysmotility, the presence of significant, new, or worsened symptoms raises the concern of scleroderma. Patients should be asked about symptoms of malabsorption. Specific questioning should be directed at eliciting a history of joint stiffness and especially muscle weakness. The latter can be approached by inquiring about new or progressive difficulty in specific tasks such as walking up steps, brushing hair, and arising from low chairs or the toilet. Distinguishing muscle weakness from general fatigue is not always easy, but it is important.

Shapiro and Wigley discuss the extremely useful evaluation of nailfold capillaries, which can be done with a standard magnifier or ophthalmoscope. This is very valuable to help predict the development or current presence of a systemic rheumatic disease. But this is not a technique that most clinicians are familiar with. A potentially useful surrogate or adjunctive test, especially in the setting of new-onset Raynaud, is the antinuclear antibody (ANA) test; I prefer the immunofluorescent assay. While a positive test alone (with Raynaud) does not define the presence of any rheumatic disease, several older studies suggest that patients with a new onset of Raynaud phenomenon and a positive ANA test are more likely to develop a systemic autoimmune disorder than if the test is negative. Those who do so (and this is far from all) are most likely to have the disease manifest within a few years. Hence, if the ANA test is positive but the history, physical examination, and limited laboratory testing (complete blood cell count with differential, complete metabolic panel, creatine kinase, and urinalysis) are normal, it is reasonable to reexamine the patient in 3 months and then every 6 months for 2 to 3 years, repeating the focused history and physical examination. It is also reasonable at some point to refer these patients to a rheumatologist.

Since Raynaud phenomenon is common, and the associated severe rheumatic disorders associated with it are rare, it is easy to not recognize Raynaud phenomenon as a clue to the onset of a potentially severe systemic disease. Yet with a few simple questions, a focused examination, and minimal laboratory testing, patients who are more likely to harbor a systemic disease can usually be treated symptomatically if necessary, and appropriately triaged to observation or for subspecialty referral.

For many patients, Raynaud symptoms are mild enough to not even mention to their primary care provider, and conversely, there is little reason for most clinicians to routinely inquire about such symptoms. So it may surprise some readers to read about the nuances of diagnosis and treatment discussed by Shapiro and Wigley in this issue of the Journal.

To a rheumatologist, Raynaud phenomenon, particularly of recent onset in an adult, raises the specter of an underlying systemic inflammatory disease. The phenomenon is not linked to a specific diagnosis; it is associated with lupus, rheumatoid arthritis, cryoglobulinemia, inflammatory myopathy, Sjögren syndrome, and, in its severe form, with the scleroderma syndromes. We focus on differentiating between these rheumatic disorders once we have discarded nonrheumatic causes such as atherosclerotic arterial disease, carcinoma, embolism, Buerger disease, medications, smoking, or thrombosis.

But rheumatologists are toward the bottom of the diagnostic funnel—we see these patients when an underlying disease is already suspected. The real challenge is for the primary care providers who first recognize the digital vasospasm on examination or are told of the symptoms by their patient. These clinicians need to know which initial reflexive actions are warranted and which can wait, for, as noted by Shapiro and Wigley, there are several options.

The first action is to try to determine the timeline, although Raynaud disease often has an insidious onset or the patient doesn’t recall the onset. New and sudden onset likely has a stronger association with an underlying disease. A focused physical examination should look for digital stigmata of ischemic damage; the presence of digital ulcers or healed digital pits indicates a possible vascular occlusive component in addition to the vascular spasm. This strongly suggests scleroderma or Buerger disease, as tissue damage doesn’t occur in (primary) Raynaud disease or generally even with Raynaud phenomenon associated with lupus or other rheumatic disorders. Sclerodactyly should be looked for: diffuse finger puffiness, skin-tightening, or early signs such as loss of the usual finger skin creases. Telangiectasia (not vascular spiders or cherry angiomata) should be searched for, particularly on the palms, face, and inner lips, as these vascular lesions are common in patients with limited scleroderma. Careful auscultation for basilar lung crackles should be done. Distal pulses should all be assessed, and bruits in the neck, abdomen and inguinal areas should be carefully sought.

Patients should be questioned about any symptom-associated reduction in exercise tolerance and particularly about trouble swallowing, “heartburn,” and symptoms of reflux. Although patients with Raynaud disease may have demonstrable esophageal dysmotility, the presence of significant, new, or worsened symptoms raises the concern of scleroderma. Patients should be asked about symptoms of malabsorption. Specific questioning should be directed at eliciting a history of joint stiffness and especially muscle weakness. The latter can be approached by inquiring about new or progressive difficulty in specific tasks such as walking up steps, brushing hair, and arising from low chairs or the toilet. Distinguishing muscle weakness from general fatigue is not always easy, but it is important.

Shapiro and Wigley discuss the extremely useful evaluation of nailfold capillaries, which can be done with a standard magnifier or ophthalmoscope. This is very valuable to help predict the development or current presence of a systemic rheumatic disease. But this is not a technique that most clinicians are familiar with. A potentially useful surrogate or adjunctive test, especially in the setting of new-onset Raynaud, is the antinuclear antibody (ANA) test; I prefer the immunofluorescent assay. While a positive test alone (with Raynaud) does not define the presence of any rheumatic disease, several older studies suggest that patients with a new onset of Raynaud phenomenon and a positive ANA test are more likely to develop a systemic autoimmune disorder than if the test is negative. Those who do so (and this is far from all) are most likely to have the disease manifest within a few years. Hence, if the ANA test is positive but the history, physical examination, and limited laboratory testing (complete blood cell count with differential, complete metabolic panel, creatine kinase, and urinalysis) are normal, it is reasonable to reexamine the patient in 3 months and then every 6 months for 2 to 3 years, repeating the focused history and physical examination. It is also reasonable at some point to refer these patients to a rheumatologist.

Since Raynaud phenomenon is common, and the associated severe rheumatic disorders associated with it are rare, it is easy to not recognize Raynaud phenomenon as a clue to the onset of a potentially severe systemic disease. Yet with a few simple questions, a focused examination, and minimal laboratory testing, patients who are more likely to harbor a systemic disease can usually be treated symptomatically if necessary, and appropriately triaged to observation or for subspecialty referral.