Table 4 Approach to Raynaud’s phenomenon and Digital Ulcer management

First line

Calcium Channel blockers

Calcium channel blockers

Second line

PDE5 inhibitor, or IV prostacyclin analogs

For the prevention of new ulcers: bosentan

For healing or prevention of new ulcers: PDE5 inhibitor, intravenous prostacyclin analogs

Third line

Prostacyclin analogs or PDE5 inhibitor

Prostacyclin analogs

Supplementary

Nitroglycerin

Digital sympathectomy analgesics, atorvastatin

Angiotensin II receptor blocker, aspirin, botulinum toxin, fluoxetine, Pentoxifylline, Hyperbaric oxygen

botulinum toxin, fat grafting

Digital sympathectomy, anticoagulation, fat grafting

General suggestions:

• Avoid cold and trauma

• Wear proper clothing

• Smoking cessation

Selected situations:

Infection:

• Consider antibiotics, wound care, and pain management in the case of infection

• Oral antibiotics to be used in digital ulcer treatment only if an infection is suspected

• In the event of an abscess or osteomyelitis, surgical debridement should be considered

• Digit or limb amputation might be warranted if gangrene is present