Managing Raynaud’s Phenomenon and Cold Extremities

Most people don’t know that I grew up figure skating in Wisconsin. That’s right, before I was a runner and a skier, I figure skated year round! One of my most vivid memories from this time is being curled up in the fetal position on a picnic table with mittens on my feet and hands crying as my numb digits rewarmed. I’ve had startlingly cold hands for as long as can remember, so much so that my brothers tease me by saying, “Cold hands, Cold heart!” However, when I joined our high-school cross-country team, I noticed a teammate who would don mittens if the temperature dipped below 60 degrees Fahrenheit. I knew immediately that I did not have the coldest hands on the team. My cross-country teammate had what I now know is Raynaud’s phenomenon, something I’ve also learned that approximately one out of every five of my female friends deals with–hold on, I promise the science is going to support me here!

So, what is Raynaud’s phenomenon? What can you do about it? And what about other cold-extremities issues such as cold injuries, the screaming barfies, and more? We’re addressing these questions in the rest of this article. While it’s definitely a niche topic, I hope it’s informative and maybe it’ll spare a few of us from acquiring the “cold hands, cold heart” moniker.

The author’s (back row, right side) figure-skating days. Image courtesy of Corrine Malcolm.

What is Raynaud’s Phenomenon?

Raynaud’s phenomenon (RP) was first described by Maurice Raynaud in 1862 as a vascular (circulation) issue that often happens with exposure to moderate cold but still “seemingly without reason” (1). During these episodes, a person’s fingers become bloodless, numb, and whitish yellow in color (2).

It took another 70 years for the etiological underpinnings of RP to become more apparent and universal diagnosis criteria to be formed. We now understand that Raynaud’s is most commonly seen with a marked biphasic or triphasic change in skin color (white to blue and sometimes to red) of the fingers (the thumb is often spared) (2). The white pallor is related to initial vasospasm/vasoconstriction (narrowing) of the blood vessels feeding the fingers, and the blue is from lack of oxygen to the tissue. If the fingers of a RP sufferer turn red, it is linked with the reperfusion (return of blood flow) which can sometimes also cause pain and tingling (2).

Vasoconstriction can be totally normal and is used frequently to help us with thermoregulation. As your core body temperature drops, peripheral (hands, feet, nose, ears, and more) vasoconstriction helps maintain your core body temperature. Likewise, when we get really warm, vasodilation sends more blood to our skin’s surface and “pushes” heat into the atmosphere around us. What makes RP an abnormal kind of vasoconstriction is that it can happen at considerably warmer temperatures and can even be triggered by stress. The medical community considers RP to be an overreaction or hypersensitivity.

On the left, the digital artery is wide (open) and has normal blood flow. On the right, vasoconstriction (narrowing) of the digital artery is restricting blood flow to the fingers and causing the discoloration. Image: Phillipsphiles.blogspot.com/2008/11/what-is-raynauds-disease.html

Is Raynaud’s Phenomenon Dangerous?

For those of us who are always just one click away from WebMD and concluding there is something seriously wrong with us–I am guilty of this–let’s talk about the two types of Raynaud’s phenomenon, primary and secondary Raynaud’s phenomenon. Primary RP is the more common and completely benign variety, whereas secondary RP is related to an underlying condition that could be more serious (3). While we can call take heart by learning that between 80 to 90% of people with RP have primary RP (4), you should speak with your primary care provider if you have RP symptoms.

Underlying conditions leading to secondary RP range in their severity. “More mild” conditions include a previous cold injury like frostbite or drug use such as estrogen-replacement therapy (because it alters blood flow) (9), anti-migraine drugs that contain ergotamine or sumatriptan (which cause vasoconstriction) (10), or beta-blockers (which slow heart rate and lower blood pressure) (10). The underlying conditions could also be more serious, like endocrine issues including hypothyroidism (which can cause a decrease in circulation) and connective-tissue disorders such as systemic sclerosis (an autoimmune disorder that attacks the body’s tissues, particularly your skin, joints, and internal organs) and chronic, systemic change in small blood vessels where they cannot return to normal size (3).

Interestingly, women are nine times more likely to have RP then men, with RP reported in as few about 1% of men and up to 20% of women depending on geographic location (3, 5). Although we do not know why this is so much more prevalent in women, we do know that there appears to be a heredity component (commonly having a first-degree relative with RP) and it is also common in people who suffer from other vasospastic conditions such as migraines (5). That’s a whole lot of white fingers!

Nikki Buurma’s hand has distinct blanching (white-yellow pallor) on all four digits that starts from the tip of the finger and ends as an abrupt line. Image courtesy of Nikki Buurma.

How to Manage Raynaud’s Phenomenon

Truthfully, the options for managing RP are not great, basically involve you staying warm, and will likely have you mumbling, “Well, duh!” As previously mentioned, secondary RP should be treated by medical professionals. Most people manage their primary RP without any medical intervention, instead opting for those easier “well duh” choices. Medical options for primary RP management include calcium-channel blockers and vasodilators (medicines which both relax and open small blood vessels in your hands and feet). However, the main tidbit of advice is identifying and mitigating what seems to trigger your vasospastic condition, and managing your thermoregulation when and where you can. The best recommendation the medical literature seems to have is “avoiding cold,” and that can be hard as a runner. If I’ve learned anything from my one-in-five female running partners, it is to always pack mittens and hand warmers.

I Don’t Have Raynaud’s Phenomenon, But I Do Have Cold Hands!

Maybe you’re like me, and you struggle with cold and maybe even painful hands but you don’t have RP. So, what gives then? A number of different scenarios could be taking place here. One distinct possibility is that you’ve experienced a non-freezing cold injury or a more serious injury like frostbite. These types of cold injuries start with your natural physiology trying to protect you. As your skin cools, you naturally experience cold-induced vasoconstriction, commonly in the hands and feet, but also in the nose, chin, earlobes, cheeks, and lips. This keeps warm blood protectively near your core, and happens in cycles lasting five to 10 minutes to conserve heat while also trying to not cause permanent damage to your extremities (6). If this cooling off is very rapid, ice crystals can form in the fluid outside of your cells, damaging cell membranes and causing the injuries you see more commonly in mountaineers that range in severity. Read more about frostbite in this iRunFar article. This type of cold injury, if repeated, can result in persistent sensory disturbances in your hands and feet including numbness, paresthesia (tingling), and chronic pain (11).

Or perhaps you are just a cold person? It turns out some people are just less tolerant of the cold than others. Sometimes this is caused by previous cold injuries such as frostbite, as mentioned above, but there are other reasons that you might be a cold person–and it’s not because you have a “cold heart.” Cold intolerance can be due to low body fat, having chronically high stress or anxiety (extra adrenaline released causes narrowing of blood vessels), disorders of the hypothalamus (the portion of your brain responsible for temperature control), and anemia (not enough blood circulating to your tissues).

There is one last condition, that I have a particular affection for, referred to in North American ice-climbing circles as the “screaming barfies” and in the worldwide community as the “hot aches.” If you’re lucky, you are sitting here wondering, “What in the world?” In fairness, both names are fairly descriptive. These conditions are usually localized to the hands or feet (most commonly the hands) and happen early in cold outdoor activities after a period of cooling or inactivity. For me, this is most common once I start skiing after spending time outside in the cold getting gear together. Most people experience pain, throbbing, and tingling which for many can progress to systemic symptoms including nausea, dizziness, transient loss of vision, and irritability (which honestly seems fair if you are trying to simultaneously cry, yell, not vomit, and if you’re me letting out a string of unmentionable words) (7, 8). Despite this being a common phenomenon, particularly in cold winter sports (about 81 to 96% of ice climbers report experiencing symptoms with about 60% experiencing them every time out), it is not understood why exactly this happens or more importantly why is happens to some people while not others (7, 8).

With so much left unknown, where does that leave us for advice? Back in the camp of practicality. Akin to dealing with primary RP or trying to avoid frostbite, there are lots of logical precautions to undertake. These include dressing appropriately for the weather conditions while maximizing loose, heat-insulating layers and avoiding constriction of body parts, opting for mittens over gloves for greater warmth and utilizing hand warmers if needed, staying dry by utilizing appropriate wicking materials like wool as opposed to cotton, and maintaining adequate hydration and nutrition to maintain normal fluid and electrolyte balances (6).

Call for Comments

  • Do you have Raynaud’s phenomenon? Can you share about it?
  • Have you experienced the screaming barfies or hot aches?
  • What additional practical advice can you share for keeping your extremities comfortable in the cold?

References

  1. Herrick, A. L. (2005). Pathogenesis of Raynaud’s phenomenon. Rheumatology44(5), 587–596. doi: 10.1093/rheumatology/keh552
  2. Wigley, F. M., & Flavahan, N. A. (2016). Raynaud’s Phenomenon . The New England Journal of Medicine375(6), 556–565. doi: 10.1056/NEJMra1507638
  3. Belch, J., Carlizza, A., Carpentier, P. H., Constans, J., Khan, F., & Wautrecht, J. C. (2017). ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon. Vasa46(6), 413–423. doi: https://doi.org/10.1024/0301-1526/a000661
  4. Pope, J. E. (2013). Raynaud’s phenomenon (primary) . BMJ Clin Evid.1119, 1-28. PMCID: PMC3794700
  5. Garner, R., Kumari, R., Lanyon, P., Doherty, M., & Zhang, W. (2015). Prevalence, risk factors and associations of primary Raynauds phenomenon: systematic review and meta-analysis of observational studies. BMJ Open5(3). doi: 10.1136/bmjopen-2014-006389
  6. Imray, C., Grieve, A., & Dhillon, S. (2009). Cold damage to the extremities: Frostbite and non-freezing cold injuries.Postgraduate Medical Journal, 85(1007), 481-488. doi:10.1136/pgmj.2008.068635
  7. Beyer, A., Ganti, A., & Byrne, B. (2017). Prevalence of the “Screaming Barfies” Among North American Ice Climbers.Wilderness & Environmental Medicine, 28(4), 367. doi:10.1016/j.wem.2017.08.013
  8. Melvin, A., & George, J. (2016). A Descriptive Study of Hot Aches: A Previously Unreported Winter Climbing Phenomenon.Sports Medicine – Open, 2(1). doi:10.1186/s40798-016-0062-z
  9. Serizawa I, Iwasaki N, Ishida H, Saito SY, Ishikawa T. G-protein coupled estrogen receptor-mediated non-genomic facilitatory effect of estrogen on cooling-induced reduction of skin blood flow in mice. Eur J Pharmacol. 2017 Feb 15;797:26-31. doi: 10.1016/j.ejphar.2017.01.013. Epub 2017 Jan 13. PMID: 28089920.
  10. Gilchrist, A. (n.d.). Common Drugs That Can Cause Raynaud’s Disease. Retrieved November 14, 2020, from https://www.pharmacytimes.com/news/common-drugs-that-can-cause-raynauds-disease
  11. Tom A Vale, Mkael Symmonds, Michael Polydefkis, Kelly Byrnes, Andrew S C Rice, Andreas C Themistocleous, David L H Bennett, Chronic non-freezing cold injury results in neuropathic pain due to a sensory neuropathy,Brain, Volume 140, Issue 10, October 2017, Pages 2557–2569, https://doi.org/10.1093/brain/awx215

There are 22 comments

  1. Sheila Boyle

    Thanks for the article. I have struggled with RD as long as I can remember and my hands are usually cold regardless of the temperature. I’m generally fine while running (though I wear gloves), but notice it most after a run when my body cools, which is why I immediately hit the shower. I resorted to heated mittens for skiing to extend my time on the mountain and find shaking my hands can help bring some blood flow back when they turn white. Never run your hands under super hot water to de-thaw and instead opt for warm. I even bought the rechargeable hand warmers to keep in my pocket on cold days. In other words, RD doesn’t mean you can’t survive the winter!

  2. John Wilson

    This article peaked my interest immediately. I am male and 62 years old. I grew up in Quebec and lived outdoors all year no matter what the weather. I got frost bite many times growing up. I first be came aware that I had Raynauds in my 20’s and it has progressively gotten worse as I have gotten older. It can be 60 degrees and my fingers will go white. I have leaned to deal with it. I agree with everything you say: hydration and nutrition are key, wear mitts, always wear a hat, carry hand warmers. I also now have heated mitts and socks that I use when I ski which are simply amazing and well worth the money. Interestingly my feet are usually fine when I run, I am ok with just regular socks so long as my core, head and hands are warm

    Best,

    John Wilson

    [Comment posted by editors on behalf of reader]

  3. Meghan Scott

    I have Raynaud’s in my feet and have had for about 10 years. I find it’s worse when I’m stressed, worried or have a cold. I can feel when my feet are just cold or when the Raynaud’s is kicking in, then I don’t mess around, I head straight to the tub to soak my feet. I own the warmest socks/boots/slippers but don’t let it affect my outdoor activities. It’s just something I have to take into consideration before I head out the door.

  4. Melanie

    I’ve struggled with Raynauds since childhood and I, too, grew up a figure skater! It’s actually the primary reason I quit skating – my feet would become too painful inside my boots. Now, as a runner, I struggle differently. Like the above commenter, my symptoms are the worst after a run when my body is cooling down. It can be 90 degrees outside and my hands/feet will still go numb. I bring a change of clothes with me to every trailhead so I can get out of my sweaty outfit immediately but a warm shower is really the only way to reset.

    1. Corrine Malcolm

      Hi Melanie, yes for former skaters! I went from that to nordic skiing so apparently just a glutton for punishment and cold digits! Although I do not have classical RP I do find that changing out of wet clothes immediately after my run (bra/shirt/shorts all must go!) does help a lot as well, but do rely on a warm shower to reset when I get to cold on my way back from the trailhead. I feel so fortunate this is primarily during/after damp runs below 60F as opposed to every time I run, or while sitting in my office.

  5. Paul Kirsch

    Hey Corrine, thanks for writing this! I have Raynauds pretty badly but have figured out how to handle New Hampshire Winters. A key thing is, most of my runs, starting in November, are done with mittens. Basic running gloves are not enough. I also find glove liners make it worse as it separates the fingers too much.

    On 10 degree and lower days, I will also use heat packs in the mittens. As Melanie mentioned above, the real danger happens after you cool down. Always good to have dry clothes to change into as soon as you stop running. Otherwise my hands immediately go white.

  6. Johanna

    I always know when the temperature is dropping close to freezing. That’s the only time my fingers go white and numb. If I’m out and about in below freezing temps and wearing gloves, my fingers are just fine. As soon as it’s just around 32F I can’t seem to keep my hand warm no matter what I do and they’ll be numb and white for an hour or so.

  7. Peter Brewer, Bend OR

    I have RP and it happens more often as I grow older… as a male who always seemed to have warm hands when younger it is strange. Yet repeated exposures to cold hands while mountain climbing seemed to have done part of the trick.
    After running, even on a 60 F day once my body starts to cool down my fingers can become white. This happens after races when I am warm for a while and forget to bundle up quickly then wham! I start to get that cold hands feeling (and cold nose), then white. Every now and then a bit blue… if I can post-colder runs I jump in the shower to warm up all over but keep trying to remember to put a hat on, dry clothes, and so forth. My friends look in disbelief at my white digits and blue nose….! And unfortunately it can happen just sitting at my desk when it may even be comfortably warm (mid to upper 60’s).
    On long colder weather runs I always bring hand warmers in case of need. During some runs and ultras my hands are so numb I can not open even a gel, and working zippers becomes a chore… not a fun position to be in as sometimes a hand warmer doesn’t really work very well either. Extra warm gloves to put on becomes as must. Sigh. !! Thanks for the article, I now have a name for this phenomena.

  8. Adam Leadbetter

    I have RP, as does my dad, as does his mum.

    For me, it tends to be set off at slightly warmer temperatures if the humidity is high. Which isn’t great for someone who grew up in the UK and now lives on Ireland’s Atlantic coastline. Even getting out of the shower during the winter can send a fingertip or two white.

    In terms of gloves, I’d love to know how much I’ve spent over the years looking for a solution. Primaloft mitts tend to be ok. Primaloft gloves tend to be ok. Thin wool glove liners tend to be ok. Winter cycling is simply painful. However, the really important thing seems to be keeping my wrists warm, and so winter jackets with thumb holes, really long cuffed gloves or wrist gaiters are a go to.

    The really odd thing is, one my hands get warm on a run, I can strip the gloves off no problem.

  9. Jenny Hitchings

    I have RD and it seems to be getting worse as I get older. The minute my core gets cold (or a chill) I know my fingers are next. I have to change out of damp running bras and clothes as soon as I’m done working out or I will get a chill. It has taken longer to get blood flow to my fingers lately. I do get ocular migraines as well, but I attribute this to hormonal issues more than anything else.

    I just had an ultrasound of extremities (neck to fingers) to see if blood is flowing…seems to be ok. I have also been advised about medications, but as a runner, I already have low blood pressure, so some of these meds aren’t the best, as they can lower your blood pressure. Sometimes if I swing my arms round and round, this gets the blood flowing to finger tips!!

    Though Rd is painful and annoying, I’m not sure what I can really do, except manage the chill…and chill! Mittens (thicker), beanies and keeping core warm helps. But most of all, getting warm before I get cold!

    I’d really like more info on this!

  10. Jocelyne

    I suffered from RS a few years back and found that ginger tablets worked wonders (recommended by my doctor, but sold over the counter).

    My symptoms affected both my hands and feet, but it was my feet that were most debilitating and extremely painful when the RS flared up.

    My RS seemed linked to my living conditions at the time (an old house that was hard to heat and thus always cold and felt damp). My symptoms largely went away when I moved to a better insulated home.

    Now, I reach for the ginger tablets if I feel like the RS is starting to return and, fingers crossed, this has largely managed to keep the flare-ups at bay for the past few years.

  11. Amie Hopp

    I’m a 46 year-old female with Raynaud’s who grew up in Northern Michigan, enjoyed winters in Maine and Montana and Minnesota and Vermont, and now lives in Austria. I remember comparing notes with a woman at a Maine Huts and Trails hut and her nodding vigorously and looking over at her boyfriend frequently to make sure he was hearing this, that he was picking up on the fact that she isn’t crazy or wimpy; she just has Raynaud’s! I call it Raynaud’s Annoyance. It doesn’t prevent me from doing the activities I want to do, I just have to have a strategy…year-round, not just in winter. Since Raynaud’s is the body’s exaggerated response to the slightest drop in core temperature, (my fingers lose circulation completely on a 90 degree summer day if I stop moving and drink a glass of cold water!) my strategies focus on maintaining my core temperature as well as on keeping my hands themselves warm. I’m the one who gets teased for her big mittens. If they only knew that inside those huge outer mittens there’s a pair of felted wool mittens and inside those, liner gloves, and between the layers, handwarmers (which I buy by the case.) I choose half-zip shirts and jackets whenever I can since matching sides of a full-zipper is pretty impossible with numb fingers. I’ve learned that the absolutely first thing I have to do at the end of a run/snowshoe/bike ride is put dry layers on. Once the damp layers I have on get cold, I’m toast…cold, numb, toast. I carry a thermos with a hot drink in it , sometimes simply hot water, to drink right at the end of an activity to prevent the core temperature drop when I stop moving. The people who love me accept (because I’ve explained it and shown them my fingers when I haven’t succeeded in keeping them warm) that I can’t stop while underway. I eat on the go, drink on the go, chat on the go, etc. I can’t stand around for photos, can’t sit for a snack, am not interested in “taking a break”. I’m not concerned about speed; I simply have to stay in motion. It takes hours for the circulation to come back in my fingers once I’ve lost it so it’s better to go a speed I can maintain so I don’t need a break and thereby stay warm. No one who hasn’t experienced Raynaud’s can really understand it but the people who love you will accept it and will allow you to do what you need to do to take care of yourself.

  12. Todd Jenkins

    I am a 59 year old male and have had RP in my hands for many years. Mine behaves a bit differently as I normally go white/numb after some type of shock to my fingers, not just cold. If I bump my fingers on a counter or a door, I’m instantly white and numb. I find that if my hands get cold slowly, I can withstand very cold temperatures, but if I reach for a tub of cold yogurt or ice cream at the store, more than half the time that will set the RP off. I typically do not wear gloves in the winter while running. I live in North Carolina, so my winters are not harsh by most standards, but I find I am fine as long as my hands cool and warm gradually. Once the RP hits, however, it can take hours to get back to normal, but all the while I have not lost any strength in my hands, only feeling. I have done entire Spartan races with all 4 fingers on one hand white and numb with no detrimental effects. I have never had any RP symptoms in my feet, but did get the screaming barfies once on a cold wet mountain bike ride and try hard to avoid those conditions now. It is interesting how many responses there are to this article, like a lot of people, I thought I was the only one with this condition. I wish the best of luck to everyone who suffers from RP and hope you can find some remedy that allows you to continue to enjoy what you love.

    1. Corrine Malcolm

      Hi Todd,
      I love that people are realizing they are not alone in their RP experiences, it’s always nice to know other people know what you are going through. Your RP sounds more traditional than some people, responding to more than cold stimuli, someone on the FB post for this article mentioned that RP can be linked to using power tools, which is caused by the vibration. I wonder if that is similar to the bumping of the fingers that you experience.

  13. Jeff Montgomery

    Thanks, this is the type of thing you want to read before it happens, because… it scared the HECK out of me the first time it happened, skiing in trees in the shade on a really cold day. My toes were white and I thought I had frostbite. Yikes.

    I’ve never had any bad side effects afterwards, so shout out to the human body being able to deal with it.

    Now I’m like, whatever. For me at least, keeping warm after an activity is key and usually prevents or reduces it.

    Pro tip: heated car seats!

    1. Corrine Malcolm

      Hey Jeff,
      It’s so scary! Toesicles are no fun. There is one more odd condition we didn’t talk about at all in this article called Chilblains (https://www.mayoclinic.org/diseases-conditions/chilblains/symptoms-causes/syc-20351097) which can effect the fingers or toes after a period of being cold and then rewarming. I have a number of friends who have experienced it in their feet over the years, and they swear by just avoiding getting cold (imagine that), lots of house slippers and warm socks. Bodies are incredible, both in their weirdness and their ability to keep us alive!

  14. Michael Dubova

    Thanks for posting this article.

    I’ve been struggling with RD since I was 11 years old (I’m currently 36).

    My toes and fingers always fall victim to going numb, even during summer months. This always leads to a loss of dexterity and function of my hands and total loss of feeling in my feet.

    It takes a couple hours for my hands and feet to ‘defrost’ and to achieve full function.

    Things I’ve tried:
    – Supplements: magnesium, gingko bilboa
    – Cold Therapy – up to 8 minutes in ice water
    – Meditation/deep breathing
    – using socks as mittens so I can keep all my fingers together
    – ignoring it

    For me, none of these have actually solved the issue.
    So it has become more about how to manage the symptoms.

    Good luck to everyone dealing with this.

  15. Jenny Hitchings

    P.S.

    Dr also recommended Krill Oil (Which I’m taking, as it’s good for overall joints and heart) and a nitroglycerine cream (Nitro-Bid 2%) which I have but haven’t tried yet.

  16. Cory Kohm

    RP usually strikes my fingers around 20-30 min after a run on cooler days. But oddly, it could hit AFTER I’ve showered and am warm and fixing post-run food. What’s made the biggest difference is rubbing my forearms to keep them warm and get the circulation going, as well as sticking toe warmers/hotties to my wrists or forearms during the activity. Usually that prevents any symptoms and even allows me to wear regular gloves Or mittens instead of big bulky insulated ones. Happy trails all.

  17. Ian

    I have RP in my hands. I found heat pads on my wrists stops the worse of it on long runs and winter ultras. Found heat pads inside glove made hardly any difference. I also find gloves that fully cover my wrists also help when not using heat pads. My RP is now almost all year round. Been know to get in in the summer on a beach after swimming. Not many people wear gloves on a beach in summer!

  18. Josh

    With only a slight adaptation this article could have been made inclusive of all runners. Instead it is narrowly focused on runners who are White. Reynaud’s does not discriminate.

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