Feb 27, 2014

TRANSCRIPT

Interviewer: Cold hands in the wintertime, that's fairly normal. But in the summer? That could be a concern. What might you have? We'll talk about that next on The Scope.

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Interviewer: It's pretty normal to have cold hands in the wintertime, but if you've got cold hands in the summertime when it's hot out, that could be a problem. We're talking with Dr. Tracy Frech, rheumatologist. It's called Raynaud's syndrome. Is it fairly common or fairly unknown? I've never heard of it before, but that doesn't mean anything.

Dr. Tracy Frech: Sure. Well, we know that it's actually a very common condition. About 8% of the population will describe hands that when they're cold or when a person is stressed out, the hands may change different colors. It's more concerning if it's certain digits. So if two fingers or three fingers are primarily changing colors, they'll go white and dusky, and then when the blood flows into the hand they become bright red.

Interviewer: Okay.

Dr. Tracy Frech: So that three different color change, white, blue and red, particularly when it's occurring in the summer months, may signify that there's an underlying rheumatic condition.

Interviewer: So when you say "cold," how cold is cold?

Dr. Tracy Frech: That's a fantastic question because here in Utah, we certainly see a lot more Raynaud's than my colleagues in California. Cold weather can trigger it, but actually just even walking to an air conditioned facility, not necessarily a cold environment, but just a change in temperature where you go from warm to a cold temperature.

Interviewer: Is my hands, like, a just frigid, ice cube cold?

Dr. Tracy Frech: Yes. When you look down, the more impressive part of it is the visual appearance of the hand looking actually white, like, there's no blood flow to a certain digit.

Interviewer: And any time that happens in any extremity, it probably should be a bit of a concern?

Dr. Tracy Frech: It should be evaluated by a rheumatologist if it's severely bothersome, for certain.

Interviewer: All right. So it's called Raynaud's syndrome. Is this the first guy that got it?

Dr. Tracy Frech: This is a physician from France who described it initially and did some important work. He used a microscope, actually, to look at the bottom of the fingernails to see if there is some changes to the blood vessels. He did some interesting work to say why it's important to use this capillaroscopy to help to determine whether it's primary or just hands just being hyperactive in response to cold or stress or whether there may be something inside the body that is more concerning and related to, perhaps, an autoimmune disease.

Interviewer: So the primary one is just some discomfort, but other than that not too much of a concern?

Dr. Tracy Frech: Exactly, but patients still will suffer. So it's a concern in the sense that patients will need to do some behavioral interventions such as keeping the hands warm, keeping the body so warm it's almost sweating at all times, having that extra pair of gloves before you go into the grocery store during the summer or putting them on before you reach into that frozen food aisle. So things that are concerning to the patient but not concerning from an internal organ involvement. Secondary Raynaud's is when you have the hand symptoms but you also have an underlying autoimmune disease, and that's really where the rheumatologist can help determine if that disease is present.

Interviewer: You showed me a picture of the secondary, and I don't even know how to describe what those hands look like. They were nasty.

Dr. Tracy Frech: Digital gangrene can occur. We call it critical ischemia or critical decrease in blood flow to the hands. That's particularly important if a patient has had a history of Raynaud's, and then all of a sudden their finger goes pale, they can't get blood flow to that finger, and a little ulcer appears at the digit. A rheumatologist should take a look at that finger soon, and an emergency room department visit would be indicative if an ulcer occurred on the finger that has a history of Raynaud's.

Interviewer: I saw that picture, and I don't know why anybody would let it get to that point in their hands. I mean, the hands were so messed up. What's going on there?

Dr. Tracy Frech: It happens rather suddenly. In a patient who's had Raynaud's for a while may rely on conservative measures, meaning that they keep their hands warm, they put them under hot water, they may take some medications to help keep blood flow, and then all of a sudden that little ulcer can occur. Within a 24 to 48 hour period, that critical change can occur, and it really is a medical emergency if an ulcer develops. It looks like gangrene. So it's something that's sudden and acute. So it's not that a person didn't come in suddenly. It just had progressed, and no amount of medication could reverse that.

Interviewer: Do you have to have stage one before stage two can hit? I mean, is there some warming that, that might happen?

Dr. Tracy Frech: That's a fantastic question. For most people, they report they have this history of kind of having cold hands every winter, and as they aged, it got a little bit more severe. There will be an occasional case of someone where it starts that is dramatic on its onset, and at that point, the diagnosis is made. So in a rare case, it can be the presenting feature, and it can be very dramatic like the picture I showed you.

Interviewer: Sure. And that person in that picture, are they going to lose their fingers?

Dr. Tracy Frech: When that gangrene occurs where the digit becomes black and necrotic, the finger is lost.

Interviewer: Is stage two more dangerous than just the finger damage? Because you're talking of an autoimmune deficiency.

Dr. Tracy Frech: Exactly. The secondary Raynaud's phenomenon is labeled secondary because it's secondary to an underlying autoimmune disease whereas the primary Raynaud's is called primary because that's really Raynaud's in and of itself.

Interviewer: Okay.

Dr. Tracy Frech: And, again, it can be problematic for patients, and you do need to treat it.

Interviewer: It's not fun.

Dr. Tracy Frech: Yeah. So you do need to treat it, but it doesn't carry that same amount of urgency as the secondary.

Interviewer: So what other types of things would happen with the secondary other than the fingers?

Dr. Tracy Frech: In the same way as you look at hands that get intermittent blood flow damage, you will see that you can get scars in the pits of the fingers. That same process is occurring in the internal organs, so it would be an internal Raynaud's. The GI tract would get intermittent blood flow and the same process of scarring can occur. So reflux, heartburn, or poor bowel motility can be seen. In particular, the periphery of the lung can be affected, and interstitial lung disease or scarring can occur. Those are probably the two most common long-term involvements that are seen, and it's particularly a disease that I specialize in called Systemic Sclerosis.

Interviewer: So it's serious?

Dr. Tracy Frech: It is serious.

Interviewer: All right. Is there a take-away message or a final thought that you'd want a listener to have?

Dr. Tracy Frech: Certainly. Any person that has Raynaud's phenomenon that's bothersome should request from their primary care provider to be evaluated by a rheumatologist who specializes in capillaroscopy. If they're concerned, this procedure can help distinguish whether there's underlying additional testing that's necessary.

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