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May 2009: Cold Hands, Warm Heart: Understanding Cold Hand Diseases

01 May 2009

Dr. Ginard Henry is a board-certified plastic surgeon at Weiss Memorial Hospital. His specialties include the treatment of vaso-occlusive diseases of the hand, such as Raynaud's disease and scleroderma.

Dr. Ginard Henry
Plastic Surgeon
Weiss Memorial Hospital
(773) 702-6302

As our unseasonably long winter finally comes to an end, the time for having cold hands is over. However, if your hands stay cold when others around you are warm, you may have a medical condition that can be treated by the hand specialists at Weiss Memorial Hospital.

Do you notice your hands turning blue or white even in mildly cool weather? Do you experience pain in your fingers at cold temperatures? Do you have to wear gloves when handling frozen foods in the grocery store? Have you noticed any permanent color changes in the skin of your hands or new wounds on your fingertips that you cannot account for?

If you answer yes to any of these questions or experience similar problems to those listed above, you might have problems with the blood supply to your hands. In any of these cases, the most important step you can take toward better hand health is to be examined by a specialist.

Normal Hand Anatomy
 Normal blood vessels of hand and fingers.Our bodies keep our hands warm primarily by regulating the blood flow that travels from the heart, down the arm, all the way to our fingertips. Blood that flows into our hands usually travels by only two arteries: the radial artery and the ulnar artery. These arteries course through the forearm into the hand on either side of the wrist. When looking at your palm, the radial artery travels on the thumb side and the ulnar artery on the small finger side. Both arteries join together in the palm and send off branches to each finger.

Right: Normal blood vessels of hand and fingers.


Cold Hand Diseases
Abnormal blood vessels of the hand and fingers, with small constricted vessels that do not travel to tips of fingers.Just like water that is piped into a house, if one of these hand vessels gets clogged or "build-up" gets deposited along the vessel walls, the downstream blood flow can be reduced or shut off completely. Certain vascular diseases act like increasing grime on pipes as they decrease the amount of space within the vessels therefore decreasing the blood flow to the hand and fingers. Without blood flow, a person's hand and fingers become cold. If continued for a long period of time, the tissue of the fingers (which are the first to become affected) can begin to die. Decreased blood flow throughout the hand can cause permanent skin changes, pain, infection and even gangrene.

Right: Abnormal blood vessels of the hand and fingers, with small constricted vessels that do not travel to tips of fingers.

There are several different types of vascular diseases that can result in cold hands. The most straight forward and usually easily treated are thrombotic emboli (blood clots). If a blood clot is formed in a vessel, it can occlude the entire flow downstream. Usually the hand has additional vessels to help take over the flow that is missing. However, if the embolus is at a critical junction or if the person has other vascular diseases in addition to the embolus, this can completely block off blood flow.

Certain types of traumatic injuries to the forearm and hand can cause emboli to form a large blood clot along the wall of a larger, upstream vessel in the wrist. Smaller clots can break off from this large clot and travel the downstream vessels, blocking off the tiny vessels in the fingers.

Raynaud's skin changes.Other more common vascular diseases are those that decrease the overall caliber of the vessels in the hands. One of the most common vascular diseases is Raynaud's. In this disease process, there is an abnormal reaction in the hand when it is exposed to cold. In a cold environment (sometimes even to temperatures of 68°F), the blood vessels in the hand constrict abnormally aggressively and for a prolonged period of time. The decreased blood flow in the fingers causes them to turn pale or white and they can become cold and numb.

Right: Raynaud's skin changes.


Raynaud's cyanosis of fingers.When the oxygen content of the fingers is depleted, they can turn a blue color—a process called cyanosis. When the fingers are warmed up again, the increased blood flow causes a red color; this process is frequently accompanied with a new onset of pain. After a while, the fingers return to normal skin color, which can be associated with swelling and tingling. This series of changes is referred to as the "white, blue, red" of Raynaud's.

Right: Raynaud's cyanosis of fingers.



Finger ulcer from Raynaud's phenomenon.Although common, not every patient with Raynaud's experiences these classic color changes. If the process becomes worse, the repeated and increasingly prolonged depletion of blood flow to the fingers can cause ulcers in the skin and tissue death (also called necrosis).

Right: Finger ulcer from Raynaud's phenomenon.


With Raynaud's, there are actually two vascular disease processes with the same name. When a patient has hypersensitive reaction to cold and no other vascular disease, this process is called Raynaud's disease (or primary Raynaud's); there is no other cause for the changes in the hand blood flow except for this abnormal reaction to cold exposure. Raynaud's disease often develops in women in their teens and early adulthood. Primary Raynaud's is thought to be at least partly hereditary, although the specific genes have yet to be identified.

When a patient experiences abnormal reactions to cold and has another vascular disease (such as lupus, scleroderma or rheumatoid arthritis), this process is called Raynaud's phenomenom (or secondary Raynaud's). Diseases associated with Raynaud's phenomenon include:

  • systemic lupus erythematosus
  • scleroderma
  • systemic sclerosis
  • rheumatoid arthritis
  • CREST syndrome
  • Sjogren's syndrome
  • Buerger's disease (Thromboangitis Obliterans)
  • obstructive arterial disease
  • carpal tunnel syndrome

Treatment
If you have one of the many vascular disorders causing cold hands, there is hope (aside from moving to Arizona). Good hand hygiene and skin care is the first step. Keeping hands well moisturized with a heavy, occlusive cream or lotion will help significantly with resistance to cold exposure and helps keeps hands warm. Lotion may need to be applied several times a day and should always follow hand washing. Dry skin enables cracking, which can lead to infections for fingers that are at risk because of inadequate blood supply. While gloves and mittens are essential for hand warmth, the key is to continue to wear them even in mild temperatures. Disposable heat packs can also be used inside of gloves to keep hands warm.

Oral medications are also used to help reduce the number of cold hand episodes and the intensity of symptoms. Calcium channel blockers are prescribed to help dilate the constricted vessels in the hand and increase blood flow to fingers. Serotonin reuptake inhibitors and other anti-depressants (such as Fluoxetine) also can be used. Vasodilatory medications can be formulated as topical creams and directly applied to the hands to encourage increased circulation.

One of the latest and most innovative therapies is treating cold hand vascular diseases with Botox injections. Yes, the medication made famous by thousands of Hollywood celebrities also is highly effective in controlling vascular spasms and insufficiency by relaxing the muscle that encircles arteries in the hand and fingers. As these muscles relax, the artery diameter increases and more blood flows to the hand and fingers. This procedure is quick and performed in the specialist's office. Most patients see a significant improvement within three to five days and the effect can last up to three months. Another non-surgical option is chemical sympathectomy, which also causes a long-acting relaxation of the arterial musculature of the arm and hand.

In some patients, the disease is severe enough to require surgery. Depending on the problem, surgery may be needed to remove a blood clot in small hand and finger vessels using microsurgery; disease segments of arteries may need to be bypassed with vessel grafts; or a digital sympathectomy may be performed to surgically cause permanent dilation of the hand and finger vessels to allow increased blood flow.

The expertise to diagnose and treat all patients with any type of vascular cold hand disease lies in the hand surgery team at Weiss. The cold hand clinic, led by Dr. Lawrence Zachary and with his colleague Dr. Ginard Henry, provides the full gamut of cutting-edge treatment modalities to bring patients back to full hand health.

For more information
If you would like more information about cold hand diseases or would like an appointment, please call Dr. Henry's office at (773) 702-6302.



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