Management of digital ischaemia in people with Raynaud phenomenon

In patients with digital ischaemia, optimising the management of Raynaud phenomenon, as well as the underlying disease, is important (for advice on managing Raynaud phenomenon, see Overview of Raynaud phenomenon).

Digital ulcers require protection and regular dressings using preparations such as povidone-iodine. Moisture-donating dressings to soften dry eschar, followed by debridement to allow healing, may be required. If ulcers fail to heal, excision of substantial underlying calcinosis may be necessary. See Guide to choosing an ulcer or wound dressing for advice on dressing choice.

Suspect infection if ulcers become increasingly painful, red and swollen. For management of infected digital ulcers, see Cellulitis and erysipelas. Remain alert to the possibility of infection spreading to cause septic arthritis or osteomyelitis.

Adequate analgesia should be given (see Using analgesics to manage acute pain).

If ulcers are resistant to treatment, admission to hospital may be necessary for administration of a potent vasodilator, such as intravenous alprostadil or iloprost, under the supervision of an experienced clinician.

Critical digital ischaemia (eg sustained digital ulceration or blanching of fingers) or necrosis is a digit-threatening event that can occur in patients with secondary Raynaud phenomenon due to an underlying connective tissue disease. Critical digital ischaemia is a medical emergency that always requires urgent specialist assessment, and usually requires hospital admission. Potent vasodilators, such as intravenous alprostadil or iloprost, are often beneficial. Anticoagulants are used if there is evidence of recent vascular thrombosis or thromboembolism. Antibiotics are required if there is associated infection. Patients with digital ischaemia can recover well with adequate therapy, so surgical amputation should be a last resort.