Raynaud's phenomenon

Raynaud's phenomenon is one of those poorly understood disorders that just beg for anthropological treatment. It is a syndrome manifested by attacks of pallor and cyanosis of the digits in response to cold. Raynaud's disease is the most common cause of Raynaud's phenomenon, accounting for 60% of patients with this disorder. Although estimates vary, recent surveys show that Raynaud's phenomenon may affect 5 to 10% of the general population in the United States. Unfortunately, current Western medical treatments involve either pharmaceuticals with harsh side effects or surgical interventions, which are equally risky. Fortunately, a new array of products and approaches are emerging for this troubling condition, which blend molecular biology with an awareness of cross-cultural and environmental perspectives.

The Anthropology of Raynaud's

The story of Raynaud's, as with most medicine, begins not in the lab but in the evolutionary origins of the human species. Humans are tropical animals, having evolved in tropical climates. As a result, we have limited physiological ability to adapt to cold temperatures and numerous health problems result from excess exposure to cold. Nevertheless, there is some physical plasticity (and great cultural plasticity) in human animals that allows us to adapt to cold climates.

In 1847, Carl Bergmann observed that within the same species of warm-blooded animals, populations having less massive individuals are more often found in warm climates near the equator, while those with greater bulk, or mass, are found further from the equator in colder regions. This is due to the fact that big animals generally have larger body mass which results in more heat being produced. A normal byproduct of metabolism in cells is heat production. Subsequently, the more cells an animal has, the more internal heat it will produce. In addition, larger animals usually have smaller surface areas relative to their body masses and, therefore, are comparatively inefficient at radiating their body heat off into the surrounding environment. In 1877, Joel Allen noted that among warm-blooded animals, individuals in populations of the same species living in warm climates near the equator tend to have longer limbs than do populations living further away from the equator in colder environments. This is due to the fact that a thin body with relatively long appendages is less compact and subsequently has more surface area. The greater the surface area, the faster body heat will be lost to the environment. In extremely cold environments, a stocky body with short appendages would be more efficient at maintaining body heat because it would have relatively less surface area compared to body mass.

In cold conditions, vasoconstriction reduces the blood flow to our extremities (fingers, toes etc.) to reduce heat loss. But in extreme cold, total vasoconstriction can lead to frost bite. Inuit (Eskimo) and highland Peruvian Indians have a genetic adaptation that cycles the level of vasoconstriction to keep the extremities safe from cold damage while not losing too much heat.

The Inuit are also known for their consumption of cold-water fish which are high in essential fatty acids. These EFAs may help them maintain peripheral circulation. Clinical studies show that omega-3 fatty acids concentrated in fatty fish such as salmon, mackerel, tuna and sardines seems to help keep blood vessels open in some people with Raynaud's disease. Research has demonstrated that fish oils inhibit arachidonic acid metabolism, which makes them useful in the treatment of autoimmune diseases like those associated with Raynaud's. Fish oils may increase blood pressure in the fingers.

Plants also contain essential fatty acids that may help Raynaud's. The oil made from evening primrose (EPO) contains a good deal of gamma-linolenic acid (GLA) also found in borage. Some studies suggest that GLA helps relieve symptoms of Raynaud's disease, especially when massaged into the fingers.

Western Diagnosis

Raynaud's is closely related to connective tissue diseases like scleroderma. It is also linked to angina and migraine suggesting a generalized defect that predisposes arteries in many regions to vasospasm. Hair loss is another less-known problem associated with Raynaud's. More recently, accelerated destruction of platelets and release of agents such as serotonin or thromboxane A2 have been proposed as causing vasoconstriction in some patients with Raynaud's phenomenon.

Raynaud's is caused by cancer chemotherapy drugs (such as bleomycin) and certain other chemicals. Nervous and muscular system damage by radiation treatments may also lead to the disorder.

People in certain occupations may be more vulnerable to secondary Raynaud's phenomenon. Some workers in the plastics industry (who are exposed to vinyl chloride) develop a scleroderma-like illness, of which Raynaud's phenomenon can be a part. Workers who operate vibrating tools can develop a type of Raynaud's phenomenon called vibration-induced white finger. In addition, people whose fingers are subject to repeated stress, such as typing or playing the piano, are more vulnerable to the disorder.

After a few years of Raynaud's, hair may disappear from the dorsal aspect of the digits. The nails grow more slowly and become brittle and deformed. The skin becomes atrophic, thin, and tight (sclerodactyly). Ulcerations may develop at the fingertips or around the nail bed. These heal slowly and may become infected. They are extremely painful, especially at night. When they heal, they leave characteristic small, pitted scars.

Pharmaceutical Treatment

These discoveries about natural variations in peripheral circulation among humans living in differing environments led researchers to pharmaceuticals that could enhance this circulation.

Drugs that block the calcium channels found in blood vessels have traditionally been the first choice of prescription medications used to treat Raynaud's syndrome (nifedipine). These drugs block the calcium channels in the smooth muscle of vessel walls, thereby preventing contraction. Unfortunately, side-effects can be severe and include dizziness, headaches, nausea, feelings of warmth or flushing, ankle-swelling, constipation, and an increase in symptoms of heartburn, which may subside once the body becomes used to the drug. Long-acting preparations may minimize these side effects.

Other commonly used drugs include reserpine, aspirin, nitroglycerine ointment and thyroid hormone. Reserpine is the best-studied drug among the group that interferes with the function of the alpha-adrenergic nervous system. It works to dilate blood vessels (as does guanethidine). Anti-platelet agents prevent platelets from clumping together to form clots, inhibiting circulation. Low-dose aspirin is a highly effective anti-platelet agent. Nitroglycerine ointment or topical prostaglandin E2 (PGE2) has been found effective in Raynaud's phenomenon. Their local relaxant action is not counteracted by reflex vasoconstriction due to changes in blood pressure that may occur when they are given systemically. A gel made from KY jelly, sodium nitrate, and ascorbic acid can increase blood flow to the forearms and fingers of people withsevere Raynaud's syndrome. It is used at the time of an attack. Increased circulating levels of nitric oxide, which helps blood vessels dilate and increases blood flow, can also be achieved by administering L-arginine or sodium nitroprusside--both of which are involved in NO production. Finally, hyperthyroidism caused by the administration of thyroid hormone is another way to combat Raynaud's. Hypermetabolism causes thermoregulatory reflex cutaneous vasodilation. The combination of triiodothyronine and reserpine is most effective.

Surgery (sympathectomy) to eliminate vasoconstrictor tone is also used but duration of benefit is limited by regeneration of the nerves.

Medications which can aggravate symptoms of RP by leading to increased blood vessel spasm include over-the-counter cold and weight-control preparations and Beta-blocker medicines used for high blood pressure and heart disease.

Environmental Adaptations

Based on field research among cold-dwelling people scientists have looked for ways to train the body's own thermoregulatory mechanisms to increase peripheral circulation. Non-pharmacological techniques to maintain enhanced peripheral circulation have also been studied by the military to improve the readiness of troops in cold environments. Having spent time living in cold outdoor environments I became aware that the body adapts somewhat to cold temperatures through increased metabolic rate and peripheral circulation if exposed to it over a steady period of time. Dr. Murray Hamlet at the US Army Research Institute of Environmental Medicine in Natick, Massachusetts, found a way to trigger this adaptation and enhance it. He devised an exercise for troops in Alaska: Place your hands in a container of water heated to 104[degrees] to 107[degrees]F (hot water from the tap) for two to five minutes while you're sitting in a comfortable room. Then go to a cold area, preferably outdoors, and place your hands in 104[degrees] to 107[degrees] water for ten minutes. Then repeat the two to five minute indoor hot soak again. While the cold environment normally makes your peripheral blood vessels constrict, the sensation of the warm water makes them open. When you repeatedly get the blood vessels to open despite the cold, you are effectively "training" your hands to counter the constriction reflex. After 50 treatments, Dr. Hamlet says, most people can go into the cold without losing circulation in their hands.

Nutritional Anthroceuticals

Closely related to pharmaceuticals, certain compounds found in common foods have been used for Raynaud's, either topically or taken internally.

Perhaps the most interesting is L-arginine, which stimulates the body to produce nitric oxide, relaxing the blood vessels and increasing blood flow. There is also some evidence that L-arginine plays a role in angiogenesis, the formation of new blood vessels. By promoting new blood vessel growth L-arginine may be able to essentially induce biological bypasses, reducing the need for bypass surgery.

Of all the Raynaud's products on the market one of the most exciting is a product called WARM CREAM [TM] which is a topical transdermal preparation of L-Arginine developed by a doctor whose wife suffered from cold hands and feet, which he formulated in his bathroom to help her with this condition. According to independent tests of this product warming usually begins in less than 10 minutes to 30 minutes. Initial finger temperatures ranged from 22[degrees]C (at these temperatures fingers are actually discolored-blue to purple) to 26[degrees]C. By 45 minutes all subjects reached finger tempera-tures of at least 34[degrees]C with maximum tem-perature reached being 37[degrees]C. These tempera-tures were maintained throughout the measurement period, which extended up to two hours in some cases but were one hour at minimum.

Subjects reported that the warmth lasted several hours beyond the end of the measurement period. The study also found that in persons with hands of normal temperatures, no warming effect occurs. Thus the potential of overheating is not present. It is important to rub WARM CREAM[TM] into the skin for 3-5 minutes, as it takes about that long for the L-Arginine to migrate from the surface of the skin into the tissue. WARM CREAM[TM] also contains capsicum, a pepper derivative. I personally tried this product and can verify that it does work to warm the hands.

Certain pro-hormones such as DHEA have proven useful for Raynaud's according to some clinicians.

DMSO can soften collagen to relieve scleroderma symptoms, help heal skin ulcers caused by diabetes and scleroderma, and relieve blood vessel constrictions common to Raynaud's phenomenon. Ask your doctor to find a medical-grade source. Almost all DMSO available to the public is industrial grade including most veterinary DMSO and products sold in health food stores and on the Internet and may not be safe for medical use.

Niacin is well-known for its talents in dilating blood vessels. In fact, a slow-release form of niacin called inositol nicotinate is available overseas as a drug called Hexopal and is prescribed precisely for Raynaud's disease. In a number of studies, people who took this drug had fewer and shorter attacks. If you try inositol nicotinate, take 500 to 1,000 milligrams three or four times a day. The inositol combination slows the release of the niacin. Niacin has been known to cause liver damage in high doses.

Vitamin E at 400 international units twice a day, along with vitamin E applied to the fingertips, is often used successfully for people with Raynaud's. Vitamin E improves blood flow through tiny capillaries by reducing the tendency for cells to stick to the sides of blood vessel walls and to each other.

Vitamin C plays a key role in the synthesis of collagen, which is the key component in the walls of blood vessels. Vitamin C is therefore essential to ensure that the small arteries that supply the fingers do not become damaged during Raynaud's attacks. In addition, vitamin C is important in the synthesis of prostaglandin El-a hormone-like unsaturated fatty acid that acts on the smooth muscle of small arteries and decreases platelet aggregation, which has been accepted as one of the most effective treatments for emergency cases of Raynaud's. Research suggests that 500 mg of vitamin C a day is effective. Vitamin C deficiency is linked to increased permanent damage from an attack.

Magnesium is known for relaxing smooth muscle, which lines the insides of blood vessels; 1,000 milligrams of magnesium a day is commonly used. Magnesium can counter the inappropriate activation of the sympathetic nervous system.

Adequate fluid intake is important since dehydration aggravates chills by reducing your blood volume. However note that caffeinated products constrict blood vessels and can interfere with circulation.

Ethno-Pharmacy

Given that most pharmaceuticals are derived from plants originally it is not surprising that plants provide their own pharmaceuticals for Raynaud's, in cheaper and often much safer form.

Indian snakeroot (Rauwolfia serpentina) for example, contains the chemical reserpine, which dilates the blood vessels. It has often been used to treat Raynaud's disease.

Mustard plasters applied to the skin cause mild irritation that increases the local blood supply. These are called rubefacients and have long been used to treat Raynaud's disease: 4 ounces of fresh ground mustard seed mixed with warm water to make a thick paste can be applied to the fingers during an attack. Other rubefacients include cloves, garlic, ginger, horseradish, stinging nettle, peppermint oil, rosemary oil and rue.

Red pepper (Capsicum, various species) is another rubefacient and is used in WARM CREAM[TM]. You can mix it with vegetable oil, EPO, borage oil or currant oil and apply to your hands or consume it in food. An unusual way to take it is by mixing it with hot water and drinking it up.

Garlic is an excellent way to increase circulation and has been shown to improve intermittent claudication.

Similarly, ginkgo is well known for its ability to promote blood flow through the brain but has also proven useful for intermittent claudication. European physicians frequently recommend ginkgo for Raynaud's.

TCM in general, views Raynaud's and related disorders such as scleroderma as caused by Yang deficiency and qi stagnation. Typical herbs in formulas include ginger (chill dispelling), baked licorice (Qi tonic), ginseng (Qi tonic), cinnamon (chill dispelling), astragalus (Qi tonic), morinda (yang tonic), Epimedium (yang tonic), bupleurum (Qi regulating) and rehmannia (blood tonic), tang-kuei (blood tonic), peony (blood tonic), cnidium (blood tonic), carthamus (blood invigorating), persica (blood invigorating), and salvia (blood invigorating.) Western studies show that ginger lowers blood pressure and cholesterol levels, and both effects help normalize blood flow all over the body, including the fingers. Acupuncture is an excellent choice for Raynaud's and a key complement to TCM herbal treatment for this disorder.

Conclusion

While Raynaud's is becoming an increasingly prevalent problem due to human migration away from warm latitudes along with lifestyle threats to thermoregulation, field-based studies are revealing new models to treat this condition drawing on the collected wisdom of millions of years of evolution.

Acknowledgements

Special thanks to Peter Schur, MD, for his advice on Raynaud's, and UpToDate[R], a clinical information service. Also thanks to Strategic Science and Technologies for providing me with a sample of their WARM CREAM[TM] to test. For more information see http://www.warmcream.com/

Tim Batchelder is a medical science writer and information technology consultant who has written protocols and articles for Life Extension Foundation and other well-known organizations in the anti-aging, medical and health fields. Please see my website www.anthrocode.com or email me at tim@anthrocode.com for related information on medical anthropology and article references.

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