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Autoimmune disease

Overcoming Inflammation When to see a rheumatologist

How to prepare for your rheumatology consultation

October 3, 2017
How to prepare for your rheumatology consultation

Rheumatologists treat well over 100 different types of diseases.  These diseases are complex and affect many organ systems.  Diagnosing a rheumatic disease is like solving a complex puzzle.  Every first consultation includes a detailed history, a physical examination, and a review of past blood work, x-rays, and documentation from your other doctors.  All these help your rheumatologist solve the puzzle.

Preparing for a rheumatology consultation is a bit like preparing for a meeting with your accountant.  You want everything organized in advance: W-2, investment income statements, IRA/pensions distributions, child care costs, etc.  You want everything neatly laid out in advance, so that your consultation is as productive as possible.

Laying the groundwork

Make sure your rheumatologist has all the information at his or her disposal well before your appointment.

  • The progress note from your referring physician. What is the question that’s being asked?
  • Your primary care physician’s (PCP) last progress note.
  • The results of any blood tests.
  • The results of any x-rays or any other imaging.
  • If you had a biopsy that relates to your symptoms (e.g., skin biopsy, kidney biopsy, lung biopsy), your rheumatologist will want to see the pathologist’s interpretation.
  • If you are transferring care from another rheumatologist, your current rheumatologist will definitely want to see that information.

Bring an updated list of your medications and allergies

It’s always a good idea to have a written updated list of all your medications and allergies.  Make sure you bring this along to your first consultation.  Do not assume that your PCP’s updated medication list is up-to-date. Some people see more than one doctor and they’re all making changes independently.

Anticipate questions your doctor may ask

Rheumatologists certainly have access to high specialized blood tests and imaging, but the medical history is by far the most important part of the consultation.  Before your visit, try to expect some questions your doctor may ask and then write them down.  Here are a few that may help you get started.

  • When did you first notice something was wrong or had changed?
  • Describe your symptoms.
  • Has this ever happened before? If so when?
  • Do the symptoms come and go or are they continuous?
  • Is there a particular time of day where they are worse?
  • What makes your symptoms worse? What makes them better?
  • Have you taken any over-the-counter medications for your symptoms? If so, which ones and did they help?
  • Do you think you have other symptoms besides joint or muscle pain that seem connected?
  • Have your symptoms caused you to make changes to your daily routine?

Anticipate questions you may have for your doctor

  • Based on what you know, what could be causing my symptoms?
  • What tests do I need to have done to help decide what my diagnosis is?
  • Are there any symptoms that I should be looking out for?
  • What kind of interventions could I do now, to help ease some of my symptoms?
  • What kind of activities should I avoid at this time? (e.g, get pregnant, run a marathon, prolonged travel, etc.)

Actively listen and participate

You may feel overwhelmed when your doctor is giving you a new diagnosis, let alone giving you a complex set of recommendations.  You’re not alone.  A study looked at how much information (when prescribing a new medication) patients retained after their doctor’s appointment.  They found that only 64% of people were able to recall all the information that they discussed during the visit[1].  Not bad, but not great.

We know that recall of information improves health outcomes in people suffering from chronic diseases like rheumatoid arthritis and lupus.  Another study looked at aspects of doctor-patient communication that lead to higher recall.  They found that active patient engagement and explicit conversations about medications improved recall.[2]  Here are a few tips about becoming a better active listener.

  • Pay attention
  • Show that you’re listening
  • Provide feedback
  • Defer judgement
  • Be candid, open, and honest in your response.

You may also want to write things down in a journal (highly recommended) or maybe you may want to bring an advocate to your consultation.  This could be a trusted friend or family member.

Conclusion

Being ready for your appointment, active listening, and asking questions to understand your symptoms is central to not only making the most of your rheumatology consultation but also, becoming an empowered patient.

Please follow this link to request a rheumatology consultation.

[1] Tarn DM, Flocke SA, New prescriptions: How well do patients remember important information? Fam Med. 2011 Apr; 43(4): 254–259.

[2] Richard C, Glaser E, Lussier MT. Communication and patient participation influencing patient recall of treatment discussions. Health Expect. 2017 Aug; 20(4): 760–770.

Diseases and Conditions

Tocilizumab: the new wonder drug for giant cell arteritis

June 7, 2017
People aged 50 years and above can develop giant cell arteritis

On May 22nd 2017 the FDA approved weekly subcutaneous tocilizumab (trade name Actemra®) to treat giant cell arteritis, a type of vasculitis that can cause blindness and in some cases death.  Why is this so important and how does this change everything?  The answer is simple.  Previously there were no effective treatments.  Rheumatologists used steroids like prednisone at high doses for months on end.  Many people would get lot’s of side effects due to the steroids and even this did not guarantee success.  Typically it takes many years for a medication to get FDA approval.  Although it did take more than a year to get approval, the process in this particular situation was fast-tracked.  Before I get into how we got to where we are today, let’s start with some background.

What is giant cell arteritis?

Giant cell arteritis is a type of large vessel vasculitis that tends to affect people aged 50 years and above.

Pay attention to the spelling, a-r-T-E-r-i-t-i-s. This is completely different from a-r-T-H-r-i-t-i-s.

Giant cell arteritis is an autoimmune disease that inflames blood vessels not joints.  More specifically, it inflames the aorta and the branches of the aorta.  Sometimes it’s also called temporal arteritis, but that’s not a good name for it because the temporal arteries are one type of artery that giant cell arteritis can affect.  We call this autoimmune disease giant cell arteritis because if you biopsy an artery you will find “giant cells” also called “granulomatous inflammation”, when you look at it under a microscope.  In fact, this is one way rheumatologists make the diagnosis.

This is an image of the human arterial system. Giant cell arteritis can affect any artery coming off the aorta

By LadyofHats, Mariana Ruiz Villarreal [Public domain], via Wikimedia Commons

What are the symptoms of giant cell arteritis?

Giant cell arteritis can present in many ways.  It really depends on the affected blood vessel(s).  If there is vasculitis in a temporal artery, then people tend to have a bad headache and a cramping pain when chewing food.  Maybe the blood vessels supplying the ears has vasculitis? This can cause a change in hearing and vertigo.  If the blood vessels supplying the eyes is affected, then it can cause blindness.  In some cases, people aren’t even aware of it.  They get a CT scan for some unrelated issue and the radiologist finds a large aortic aneurysm.  Giant cell arteritis is a condition that causes inflammation throughout the body, so many people present with fevers, drenching night sweats, and weight loss.

One of the most common presentations of giant cell arteritis is polymyalgia rheumatica.  Sometimes doctors simply call it “PMR”.  While 40% of people with giant cell arteritis have polymyalgia rheumatica, 10-20% of people with polymyalgia rheumatic develop giant cell arteritis.  Polymyalgia rheumatica is an autoimmune disease that causes muscle pain and stiffness in the shoulders, neck, hips, and thighs.  Finally, like giant cell arteritis, it affects people aged 50 years and above.

How do you diagnose giant cell arteritis?

There are many ways to diagnose giant cell arteritis.  First of all, blood tests like the CRP and the sed rate are usually very high.  These are tests that measure the amount of inflammation in your body.   Ideally you want to have a biopsy of the affected blood vessel but sometimes that’s not possible.  The biopsy should show giant cells but this only occurs in about 50% of cases so having a negative biopsy does not necessarily completely exclude disease.  When a biopsy is not possible, certain imaging studies can help like ultrasound, CT angiography, and PET scans.

How is giant cell arteritis treated?

Steroids, steroids, and more steroids.  If a doctor suspects that someone has giant cell arteritis, they immediately start treatment with high doses of steroids.  This happens even before the workup!  Once the diagnosis is firmly made the steroids are slowly tapered.  This happens over months.  It’s not uncommon to still be on steroids for YEARS after the diagnosis.  In many cases, the vasculitis returns.  This can be very frustrating and upsetting.  Rheumatologists have tried to treat people with medications like methotrexate in addition to steroids, but these haven’t really worked.

That is until now…

How it began

In 1990 researchers tested the blood of 15 people who had untreated giant cell arteritis.  They found high levels of a cytokine called interleukin 6 (IL-6) in their blood.  After treatment with steroids, their interleukin 6 levels decreased except for a few people.  Which is unsurprising since many people with giant cell arteritis relapse.

At that time, we didn’t have any medications that specifically blocked interleukin 6.

Flash forward to 1997.  A company based in Japan called Chugai Pharmaceuticals began research on tocilizumab to treat rheumatoid arthritis.  Tocilizumab is biologic humanized monoclonal antibody that blocks interleukin 6. Then in 2003 Genentech co-developed the medication.  Genentech’s tocilizumab is called Actemra®. Finally in 2010 the FDA approved Actemra® for to treat moderate to severe rheumatoid arthritis.

Giant cell arteritis and tocilizumab

Now remember how researchers found high levels of interleukin 6 in the blood of people with giant cell arteritis? What would happen if you treated someone who has giant cell arteritis with tocilizumab?  Would they go into remission?  Maybe you could taper off steroids more quickly?  That’s exactly what some Swiss scientists showed in 2011.  They treated 5 people with giant cell arteritis with tocilizumab.  All of them went into remission and all of them were able to taper off the steroids quickly.  The elevation and blockade of interleukin 6 appeared to be especially relevant for the treatment of giant cell arteritis.  But this was a case series with a very short follow-up time.  Was this a fluke or were they onto something?

In 2012, researchers started a larger phase 2 study.  This time they studied 30 people and they randomized them to either receive tocilizumab+prednisone or placebo+prednisone. The results were favorable:

  • 85% of the people who received tocilizumab and 40% of the people who received placebo went into remission by week 12.
  • 15 % of the people who received tocilizumab relapsed, where 80% of the people who received placebo relapsed by week 52.
  • People who received tocilizumab on average stopped prednisone 12 weeks in advance compared to people who received placebo.
  • 35% of people who received tocilizumab had a serious side effect, where 50% of people who received placebo had a serious side effect.

The last act

At last year’s American College of Rheumatology conference, Dr. John Stone presented data from the GiACTA trial, which was a randomized, double-blind, placebo-controlled trial.  This was a phase 3 study.  So they looked at more people from various locations.  There were 251 people placed into 4 different groups.

  • A short course of prednisone (26 weeks) + a weekly subcutaneous placebo
  • A long course of prednisone (52 weeks) + a weekly subcutaneous placebo
  • A short course of prednisone + weekly subcutaneous tocilizumab
  • A short course of prednisone + every other week subcutaneous tocilizumab

The results

  • 56% of people who received weekly tocilizumab achieved and stayed in remission after 12 months.
  • 53.1% of people who received every other week tocilizumab achieved and stayed in remission after 12 months.
  • 14% of people who received a short course prednisone + placebo were in remission after 12 months (p <0.0001).
  • 17.6% of people who received a long course of prednisone + placebo were in remission after 12 months (p ≤ 0.0002).
  • People who received tocilizumab received about half as much prednisone overall.
  • Adverse events were about the same in all groups and there were no deaths or vision loss.

The conclusion

Due to these extraordinary results and the dire need for effective treatment for giant cell arteritis, the FDA approved weekly subcutaneous tocilizumab.  I don’t know about you, but I’m very excited about this!  Finally a medication that works!  Mind you, it doesn’t work in every single case but this is definitely is a step forward.  And to add icing on the cake, although tocilizumab doesn’t eliminate the need for steroids, it does drastically decrease the total amount people get…another big plus.

To continue learning more about rheumatology and how to read research articles from their original source, please read on!

References

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm559791.htm

Rheumatology Secrets, 3rd edition

Dasgupta B, Panayi GS. Interleukin-6 in serum of patients with polymyalgia rheumatica and giant cell arteritis. Br J Rheumatol. 1990 Dec;29(6):456-8.

https://www.drugs.com/history/actemra.html

Seitz M, Reichenbach S, Bonel HM, Adler S, Wermelinger F, Villiger PM. Rapid induction of remission in large vessel vasculitis by IL-6 blockade. A case series.Swiss Med Wkly. 2011 Jan 17;141:w13156. doi: 10.4414/smw.2011.13156.

Villiger PM, Adler S, Kuchen S, Wermelinger F, Dan D, Fiege V, Bütikofer L, Seitz M, Reichenbach. Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial.Lancet. 2016 May 7;387(10031):1921-7. doi: 10.1016/S0140-6736(16)00560-2. Epub 2016 Mar 4.

Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, Brouwer E, Cid MC, Dasgupta B, Rech J, Salvarani C, Spiera RF, Unizony SH, Collinson N. Efficacy and Safety of Tocilizumab in Patients with Giant Cell Arteritis: Primary and Secondary Outcomes from a Phase 3, Randomized, Double-Blind, Placebo-Controlled Trial [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). http://acrabstracts.org/abstract/efficacy-and-safety-of-tocilizumab-in-patients-with-giant-cell-arteritis-primary-and-secondary-outcomes-from-a-phase-3-randomized-double-blind-placebo-controlled-trial/. Accessed May 29, 2017.

Diseases and Conditions Overcoming Inflammation

Simple and easy ways to hydrate your skin

January 23, 2017

This past Christmas, I received probably one of the most bizarre gifts I have ever received.  A full adult-sized onesie! Let me tell you, it hasn’t really brought out the most flattering bit of my anatomy.  Last year I had lamented that my house was kind of cold in the winter and mentioned that babies had it made with their one-piece pajamas.  That being said, I decided to use my family’s superhuman memory to my advantage.  This year it was all about my dry skin and how wonderful it would be to have a paraffin wax machine.

I have to admit it though, that onesie does keep me nice and toasty at night!

While waiting for the paraffin wax machine that hopefully will be making its apparition Christmas 2017, hint-hint, I thought I’d do a little research about the topic of dry skin: anatomy, immunology, and basically how to keep it as moist as possible without that oily feeling.  People who suffer from autoimmune diseases tend to suffer from dry skin.  This really isn’t surprising.  This skin is the largest organ in the human body.  Because of its large surface area, it needs a large complex immune system.  Autoimmune diseases = inflammation and inflammation involving the skin = dryness, irritation, and itchiness.

Anatomy and immunology

The medical term for dry skin is xerosis and the term dermatitis signifies inflammation of the skin.  The skin is made up of the epidermis which is the most superficial layer followed by the dermis and then the subcutis.  These layers are made up of blood vessels, hair follicles, as well as glands.  One of the main functions of the skin is to protect your body from the outside world.  That being said, the skin contains many immune cells such as Langerhans cells, neutrophils, eosinophils, and lymphocytes.  When skin is irritated by bacteria, viruses, chemicals, the immune system kicks in to fight off the foreign invader.  With autoimmune diseases, it’s the immune system that starts to attack the skin itself.  In either case, when the immune system is activated it causes inflammation which = irritation + dryness.

There are many autoimmune diseases that affect the skin.  Some of these include scleroderma, Sjögren’s syndrome, rheumatoid arthritis, lupus, sarcoidosis, and psoriasis.

So what can you do to keep your skin moist and healthy? Drink plenty of water, limit the amount of exposure of your skin to water, protect your skin from the sun, avoid allergens, and moisturize regularly.

Avoiding irritation and dehydration

You would think that more water equals more hydration.  That may be true for ingested water, but it’s the opposite for water that makes direct contact with your skin.  For example, every healthcare worker soon learns that there is a positive correlation between the dryness of their hands with the amount of times they wash their hands per day.  Don’t get me wrong washing your hands is very important to prevent the spread of infection, but it certainly does a number to your skin.  Some things simply cannot be avoided.  That being said, if you suffer from dry skin, try to limit the amount of time you spend washing in the shower.  Make it a quick 5 min instead of a long 30 min shower.  Another tip is to use lukewarm water instead of hot water.

For people who shave, try to shave immediately after you shower.  The hair will be much more malleable at this time.  Always use a sharp razor and always shave with the line the hair grows.  These will lessen the amount of irritation caused by shaving.

This may sound obvious, but it’s really important to prevent your skin from burning.  Burnt skin = dehydration.  If you plan on being in the sun, try to stay in the shade between 11 AM and 3 PM.  The UV is at its highest during these hours.  Aim to cover up with clothing made of light-colored cotton.  Light colored clothing adds a few extra SPF points.  Broad-brimmed hats and sunglasses are your friends.  Use sunscreen liberally.  At least 15 SPF.  For people suffering from lupus, plan for a much high SPF as UV can actually trigger a full-fledged systemic flare.

What I mean by avoiding allergens means, try to avoid anything that may cause some form of allergic reaction.  Again allergic reaction = inflammation = deterioration of skin barrier function = dehydration.  Obviously, it’s impossible to avoid everything but it may be a good idea to swap perfumed household products for hypoallergenic ones: laundry detergent, softener, soap, shampoo, moisturizer etc.  Anything that directly or indirectly makes contact with your skin.  It’s important to note that even, “all natural” products can potentially contain allergens.  For example, most people aren’t allergic to Shea butter, but some are.  Learn to know your skin.

Hydrate you skin

Are you as confused as I am when it comes to moisturizers?  Which ones are good?  Which ones are bad?  What’s the difference between a lotion, cream, and an ointment?  What goes where?  How much should I apply?  How often?

It’s essential to moisturize daily particularly those suffering from dry skin conditions.  Simply put, dry skin is determined by the amount of transepidermal water loss and this in term is determined on the integrity of the skin barrier function.  The composition of the moisturizer determines whether the treatment helps skin barrier function or not.  I can’t tell you which moisturizer is better than the other, because I haven’t found any blinded head-to-head evidence-based studies addressing this topic.  If you do find one, let me know.  I’m all ears!

Moisturizers come in various forms: lotions, creams, and ointments.  Lotions are the least greasy and ointments are the greasiest.  Typically, the greasier the moisturizer, the longer it lasts.  The questions what goes where and how often and how much to apply, may actually be over-complicating the matter.  The goal is to keep the skin nice and hydrated.  When you really think about it, consistency is key.  Would you wear a thick greasy ointment on your hands all day long?  I wouldn’t because it’s uncomfortable and quite frankly not practical.  Due to my job description, I wash my hands nearing 100 times a day.  I’d rather use a cream or lotion and simply apply it more often.  The ointment might be better tolerated at night before going to bed?  If I’m comfortable, I’m more likely to wear the moisturize regularly.  How much to apply?  Apply enough so that the skin feels moist.

Like I said, there’s no need to complicate things.

One word of advice, when applying a moisturizer, try to stoke it onto the skin in the direction that the hair naturally falls.  This can prevent folliculitis.

Caution

A little bit about miracle cures.  They don’t exist.  Any product marketing itself to be a “cure for psoriasis”, is probably a product to be avoided.   A lot of these products have high doses of corticosteroids, which may initially make the skin look more hydrated and look “healthier”.  If you suffer from psoriasis, it may even clear it up.  But in the long run, regular application will cause permanent skin thinning, aging, and atrophy.  Just like food, read the ingredients on the packaging of your moisturizer.

When it comes to diet, in general beware of any diet advocating cutting out lists of foods.  For the most part, these are not founded in evidence and you actually may be doing more harm than good.  Nothing beats a clean diet and plenty of water.  What that actually means, is a matter up for debate.  For more information regarding clean eating, I recommend visiting the Blue Zone Project by Healthways.  The Blue Zone principles were derived from a National Geographic study identifying practices in cultures where people tend to live longer, i.e., greater than 100 years of age, and healthier as compared to the normal population.  When you have entire populations of people living longer and healthier over  thousands upon thousands of patient years, it makes me think they’re onto something.

Parting words

I hope you’ve found this information useful.  If you would like more information, please contact your local physician.  Love your skin, keep it nice and hydrated!

References

Dermatology Secrets Plus, 5th edition copyright 2016 by Elsevier

American Academy of Dermatology

Loden M. Effect on moisturizers on epidermal barrier function. Clin Dermatol. 2012 May-Jun;30(3):286-96.

Penzer R. Providing patients with information on caring for skin. Nurs Stand. 2008 Nov 5;23(9):49-56.

Diseases and Conditions When to see a rheumatologist

8 important warning signs of scleroderma

November 28, 2016
Scleroderma is an autoimmune disease that can cause fibrosis of skin and internal organs. Early diagnosis is very important. Read on to learn more!

If I had to pick one autoimmune condition, which causes chills to run down one’s spine, I pick scleroderma.  The medical name for this condition is systemic sclerosis.  In a nutshell, systemic sclerosis is an autoimmune disease which causes inflammation in small blood vessels, which eventually can cause hardening of the skin and other major organs.

I quick Google search of scleroderma will inevitably present you with a horror show of images and stories from sufferers of this condition.

Yes, scleroderma is a terrible disease, but it’s also a terribly heterogeneous disease meaning that no two cases of scleroderma are the same.  There are mild cases and there are life-threatening cases.

Identification of early disease is probably one of the most important determinants of prognosis.  Well actually, it’s a little more complicated than that, but it is the one aspect that you can control:  The knowledge to know when to ask.

Types of Scleroderma

This is how rheumatologists breakdown scleroderma:

Classification of scleroderma

 

Basically, systemic sclerosis is when the disease affects the skin and internal organs and localized scleroderma is when it only involves the skin.  A lot of rheumatologists, included yours truly, believe that localized scleroderma and systemic sclerosis are actually two completely different diseases.

I’m going to concentrate on systemic sclerosis going forward.

Now we’re left with scleroderma sine scleroderma, limited systemic sclerosis, and diffuse systemic sclerosis.  Scleroderma sine scleroderma is systemic sclerosis involving the organs but not involving the skin.  This is super rare.

People that have limited systemic sclerosis have hardening of the skin that does not go past the elbows or knees.  They also tend to NOT have kidney involvement or inflammation of the lungs.  The disease course usually is insidious and sometimes is very difficult to detect, particularly during a 15 minute doctor’s appointment.

The last type is called diffuse systemic sclerosis.  It’s important to detect REALLY fast because it can progress quickly, because it can be deadly, and people simply do better when they’re treated early. People suffering from this type of scleroderma can have whole body hardening and are more prone to develop lung inflammation and kidney involvement.

Raynaud’s phenomenon

Almost everyone with any form of systemic sclerosis has something called Raynaud’s and esophageal reflux.  They also tend to appear early during the disease process, so these two symptoms are important to watch out for.

They say a picture is worth a thousand words.  Here’s an example of Raynaud’s… not the most dramatic example but that’s kind of the point.

This is a nice example of Raynaud's phenomenon. Sometimes the finger can be white, like the pinky, and sometimes it can look dusky

 

Raynaud’s can involve your fingers and your toes.  Exposure to cold can cause it as well as a rapid change in temperature, and stress.  Raynaud’s is very common in women and for the most part is annoying but nothing serious.  The picture above is actually my hand.  This has been going on since my teens.  Let me tell you, I grew up in Canada.  Shoveling snow was kind of brutal.

About 15% of women have primary Raynaud’s (i.e., Raynaud’s without any underlying autoimmune condition).  Primary Raynaud’s typically first appears during one’s teens or early adulthood.  People with scleroderma tend to develop it later in life and  the intensity is A LOT more severe.  Sometimes the skin can become so ischemic (poor circulation) that it can cause an ulcer.  I have a lot of patients whom I’ve diagnosed with systemic sclerosis that told me that they thought that they had purple fingers because they were getting old…  This is NOT part of the normal aging process.

  1. Onset of Raynaud’s at a later stage in life.
  2. Raynaud’s complicated by ulcers.

Heartburn

Another symptom found in almost all people suffering from systemic sclerosis is heartburn.  This can present as chest pain, burning pain up your esophagus, nighttime cough, an acid taste in your mouth in the morning.  Sometimes people may have difficulty swallowing food and water.  Now, a lot of people have heartburn.  Just because you have heartburn, does not mean you have scleroderma.  You have to look at the entire picture.

  1. Heartburn
  2. Difficulty swallowing

Other common symptoms

Here is a list of other symptoms to watch out for:

  1. Puffy fingers, VERY high yield symptom
  2. Red spots all over your face, chest, and/or palms
  3. Hardening of the skin
  4. Shortness of breath with exercise

 

Conclusion

There are a lot more symptoms that I haven’t gone over.  But sometimes less is more.  If you can remember these 8 warning signs, you have a really good chance of detecting early disease on your own, and maybe even save your life or the life of a loved one.  Having more than one of these symptoms should prompt you to consult a rheumatologist for further evaluation and testing.

For more information, I highly urge you to visit the Scleroderma Foundation website. They provide useful information about scleroderma for both the newly diagnosed and those that have had the disease for a long time.  They’re also involved research and patient advocacy.  Needless to say, I highly recommend them!

If you want to learn more about Raynaud’s phenomenon and ways how to treat it, read on.

References

Rheumatology Secrets 3rd edition

van den Hoogen F, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Ann Rheum Dis. 2013 Nov;72(11):1747-55.

Minier T, et al. Preliminary analysis of the very early diagnosis of systemic sclerosis (VEDOSS) EUSTAR multicenter study: evidence for puffy fingers as a pivotal sign for suspicion of systemic sclerosis. Ann Rheum Dis. 2014 Dec;73(12):2087-93.

Scleroderma Foundation: http://www.scleroderma.org/site/PageServer#.WTC56WjytPY

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