Raynaud's phenomenon Investigation and management Clinical history Obtain a thorough history and examination from all patients presenting with RP to ensure correct diagnosis of any underlying connective tissue disease. B Laboratory evaluation Obtain basic laboratory testing (CBC, antinuclear antibodies, ESR or CRP) in all patients presenting with RP. B Capillaroscopy Obtain capillaroscopy, when available, in all patients presenting with RP. B Ensure capillaroscopy is carried out using equipment of good optical quality and by an experienced operator, usually in secondary or tertiary care. B Calcium channel blockers Offer CCBs as first-line pharmacological treatment for patients with RP in whom lifestyle modification alone has failed. A Use slow-release nifedipine in patients in whom CCB therapy is instituted, to minimise vasodilatory side effects. B Increase dosage gradually to minimize the risk of side effects. B Encourage patients to tolerate minor side effects for two to three weeks, as they may subside with time. B Lifestyle modifications Advise lifestyle modifications such as dressing warmly, ceasing smoking, and avoiding triggers such as cold. B Obtain an occupational therapy assessment for aids if difficulties are reported. B Management of digital ulcerations Q Does the patient have systemic sclerosis-related digital ulceration? Yes Consider offering surgical management of RP in exceptional situations only, such as systemic sclerosis-related digital ulceration, given the lack of good evidence in its support. C No Indications for specialist referral Q Is the patient under 12 years old? Q Does the patient show evidence of an associated disorder or of occlusive vascular disease? Q Are patient's symptoms severe or progressing despite first line lifestyle and drug treatment? Yes to any Refer patients to secondary care when there is evidence of an underlying systemic disorder, when there are signs of occlusive vascular disease, or when symptoms are severe or progressing despite lifestyle modifications and first-line drug treatment. B Refer children under age 12 to secondary care, as primary RP is less common in these age groups. B No to all Continue management and follow-up as clinically appropriate.