Raynaud's phenomenon is a spasm of the small arteries in the fingers. In the cold, or under stress, the fingers turn white and numb, then blue, then red and painful as the blood returns, over five to twenty minutes. For most people it is a nuisance managed by keeping warm and avoiding triggers, and it does no harm. For a smaller number it is severe, linked to another condition, or progresses to fingertip sores that will not heal. Our role is to confirm what it is, exclude the things that mimic it, and offer what medication cannot: botulinum toxin injections, surgery to release the arteries from the nerves that make them spasm, and care of a fingertip that has broken down.
What is Raynaud's phenomenon?
Blood flow to the fingers is regulated by small muscles in the artery walls, which tighten in the cold to keep heat in the body. In Raynaud's that response is exaggerated. The arteries clamp down hard, the finger goes white, then blue as the remaining blood loses its oxygen, then red and painful as the vessels open again.
There are two forms. Primary Raynaud's, sometimes called Raynaud's disease, occurs on its own, usually starts in the teens or twenties, affects both hands and does not damage the fingers. Secondary Raynaud's is caused by something else, most often a connective tissue disease such as scleroderma or lupus. It starts later, is often asymmetrical and more severe, and it is the form that produces fingertip ulcers. Telling the two apart is the most important part of the assessment.
Symptoms
Most people describe:
- Fingers that go white and numb in the cold, in air conditioning or when handling frozen food
- A colour change from white to blue to red, with throbbing pain as the colour returns
- Attacks lasting five to twenty minutes, brought on by stress as well as cold
- One or more fingers involved, usually sparing the thumb
Signs that point to the secondary form and need investigation:
- Attacks that started after the age of thirty, or in one hand only
- Painful cracks, sores or ulcers at the fingertips that are slow to heal
- Tight, shiny or thickened skin on the fingers
- Joint pain, a rash, mouth ulcers or difficulty swallowing
Causes and risk factors
Primary Raynaud's has no identified cause. It is more common in women and in people with a family history. Secondary Raynaud's is caused by:
- Connective tissue disease, particularly scleroderma, lupus, Sjögren's syndrome and mixed connective tissue disease
- Occupational vibration, from years of power tools, chainsaws or jackhammers
- Smoking, which both causes and worsens it
- Medication, including beta blockers and some migraine treatments
- Damage to the artery itself, from repeated blows to the heel of the hand, a clot or an old injury
Caffeine and nicotine provoke attacks in either form.
How it is diagnosed
The history usually makes the diagnosis. The consultation is about which form you have and whether anything other than Raynaud's is going on.
We examine the fingers for ulcers and skin and nail changes, look at the small vessels at the base of the nail under magnification, and check the pulses at the wrist and the flow to each finger. A blood test looks for the antibodies that mark connective tissue disease. A Doppler ultrasound shows whether the arteries in the wrist and palm are open, and a CT angiogram is arranged where a blockage rather than a spasm is suspected, because a blockage needs a different operation.
Where the findings point to a connective tissue disease, we refer you to a rheumatologist, who treats that disease while we look after the hand.
Non-surgical treatment
Most people never need more.
Avoiding triggers
Keep the whole body warm, not just the hands, because the fingers close down to protect the core. Gloves before you get cold rather than after, hand warmers in winter, a glove for the freezer section. Stop smoking, cut caffeine, and review with your GP any medication that may be contributing.
Medication
A calcium channel blocker such as nifedipine, taken daily through winter, relaxes the arteries and reduces the number and severity of attacks. It is prescribed by your GP or rheumatologist and is the standard first medication. Glyceryl trinitrate ointment applied to the fingers helps some people.
Hand therapy
GRIP Hand Therapy is on site and no referral is needed. The therapists fit protective padding for a vulnerable fingertip and teach the hand care that keeps a crack from becoming an ulcer.
Botulinum toxin injections
Botulinum toxin injected around the arteries at the base of the fingers blocks the nerve signal that makes them clamp down. It is an established treatment for severe Raynaud's and for healing fingertip ulcers, although it is not a registered use of the drug, which we discuss with you. The injections are given in the palm under local anaesthetic as a short procedure, using 50 to 100 units spread across the hand. The effect appears within a week, lasts three to six months and can be repeated. Temporary weakness of the small hand muscles occurs in a minority.
When surgery is needed
Surgery is for the severe end: fingertip ulcers that will not heal, constant pain, or a finger whose blood supply is threatened, where triggers, medication and botulinum toxin have not been enough. It is uncommon, and almost always the secondary form.
The operation
A digital sympathectomy strips the outer layer of the arteries in the palm and at the base of the affected fingers, where the nerve fibres that cause the spasm run in the artery wall. Removing that layer stops the artery responding to those signals, and the finger stays warmer. The artery itself is left intact. Where the artery is blocked rather than in spasm, the blocked segment is bypassed with a vein graft instead, a different and longer operation.
It is done under the operating microscope through an incision in the palm, as a day procedure under a general anaesthetic with a local anaesthetic for comfort afterwards, and takes 60 to 90 minutes depending on how many fingers are treated. The wound is closed with sutures under a soft hand dressing.
Ulcer care. A fingertip ulcer that has become infected or exposed bone is cleaned surgically, dead tissue is removed and the finger is dressed and protected while it heals. Where the end of the finger has died, the smallest possible amount is removed and the fingertip is closed.
Recovery, week by week
Indicative, for a digital sympathectomy.
Day of surgery. Home the same day. The fingers may feel numb for one to three days from the local anaesthetic, and are often warmer straight away.
Days 1 to 5. Keep the dressing clean, dry and elevated. Move the fingers from the start.
Days 5 to 14. The soft dressing comes off at day 5 to 7, leaving a tape bandage. Use the hand lightly.
Two weeks. Review and suture removal. Existing fingertip ulcers are reassessed and dressed.
Two to six weeks. Palm tenderness settles. Hand therapy for scar care if needed.
Six weeks onwards. Fingertip ulcers that are going to heal have usually done so by six to twelve weeks.
Driving and work. Driving and office work at one to two weeks, light manual work at two to four weeks, heavy work at four to six weeks.
Risks and complications
Digital sympathectomy is a safe operation and complications are uncommon. They can include:
- Wound healing problems or infection. More likely where the blood supply is already poor.
- Nerve injury. The digital nerves run beside the arteries. Numbness along one side of a finger is uncommon and usually temporary.
- Recurrence. The benefit can fade over years as the nerves regrow, particularly in scleroderma, and an ulcer can return if the underlying disease progresses.
- Bruising, ongoing palm tenderness, stiffness or slower than expected recovery.
When to be seen sooner
Contact us, or see your GP, if you have:
- A fingertip that stays white or blue and will not pink up in the warmth, which is an emergency
- A fingertip sore that has not healed in two weeks, or that is black, smells or exposes bone
- Redness, spreading pain or fever after an injection or an operation
If you have had surgery with us and have questions or concerns afterwards, phone the rooms during office hours on (08) 7127 0365.
Frequently asked questions
Is Raynaud's dangerous?
Primary Raynaud's is not. It is uncomfortable and does not damage the fingers. Secondary Raynaud's can be, because the arteries themselves become diseased and the fingertips can break down, which is why the first job is to work out which you have.
Why see a hand surgeon rather than a GP or rheumatologist?
Most people do not need to. Your GP manages the common form and a rheumatologist any connective tissue disease behind it. A hand surgeon is useful when the diagnosis is unclear, when a blocked artery needs excluding, when a fingertip has broken down, or when medication has failed and botulinum toxin or surgery is being considered.
Does botulinum toxin really work for Raynaud's?
For many people with severe Raynaud's, yes. It reduces pain and attack frequency and helps fingertip ulcers heal, and the effect lasts months. It is not a registered use of the drug, and we discuss that with you before using it.
Will surgery cure it?
No. A digital sympathectomy stops the treated arteries responding to the nerve signals that make them spasm, which keeps the fingers warmer and heals ulcers. It does not treat the disease behind secondary Raynaud's, and the benefit can fade over years.
How long does the operation take, and will I be awake?
About 60 to 90 minutes, depending on how many fingers are treated, as a day procedure under a general anaesthetic. Botulinum toxin injections are a short procedure under local anaesthetic in the rooms.
What does the treatment cost?
You will receive written informed financial consent setting out the surgeon, anaesthetist and hospital fees, your Medicare rebate and your health fund's contribution before anything is booked. Phone the rooms on (08) 7127 0365 for an estimate.
Do I need a referral?
A referral from your GP or another specialist means you can claim a Medicare rebate on the consultation with a surgeon. We can see you without one, but the rebate will not apply. No referral is needed for GRIP Hand Therapy.
Written and clinically reviewed by Dr Paul van Minnen, MD, PhD, EBOPRAS, FRACS (Plast)
Last reviewed 8 November 2026