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Original Research (Original Article) 


Roaa Aljohani et al, 2020;4(3):706–710.

International Journal of Medicine in Developing Countries

Prevalence of primary Raynaud’s phenomena among healthy medical students in the Western region of Saudi Arabia

Roaa Aljohani1, Halah Izzeldin Abuzaid2*, Rahaf Eid Alhazmi2, Ala Abdulrahman Sdaqir2, Soliman Masoud Amer3

Correspondence to: Halah Izzeldin Abuzaid

*Medical Interns, College of Medicine, Taibah University, Medina, Saudi Arabia.

Email: halaez222 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 05 January 2020 | Accepted: 23 January 2020


ABSTRACT

Background:

Raynaud’s phenomenon (RP) results from overactivation of small peripheral vessels to cold or mental stress. People usually present with tri- or biphasic color changes accompanied by neurological symptoms such as numbness or tingling. There are two types of RP: primary and secondary. The primary RP is common in the young age group and associated with more benign disease course. Thereby, this study aimed to evaluate the prevalence and characteristics of primary RPs among medical students in the Western region of Saudi Arabia.


Methodology:

This was a questionnaire-based cross-sectional study carried out among medical students of Taibah University, Saudi Arabia, between November 2017 and April 2018. The questionnaire included responses related to RP symptoms, risk factors, and associated diseases.


Results:

Of 300 students who responded to the questionnaire, 16 (5.3%) students reported RP based on the UK Scleroderma Study Group definition. The age of the majority of the participants was between 20 and 30 years. RP was observed more frequently in females (p = 0.005). Neurological symptoms were reported in 10 students (62.5%) with definite RP. Increase caffeine consumption, usage of contraceptive pills, and migraine were frequently found risk factors in students with RP (p = 0.05, 0.003, and 0.01, respectively).


Conclusion:

The prevalence of RP is relatively low as compared to previous studies. Geographical distribution, genetics, or both might be the cause for these results. Female gender, more caffeine consumption, usage of contraceptive pills, and migraine were more frequently found risk factors in students with RP.


Keywords:

Prevalence, Raynaud’s phenomena, medical students, Saudi Arabia.


Introduction

Raynaud’s phenomenon (RP) is a clinical condition that results from an exaggeration of the body’s normal physiological response to cold or mental stress, which causes peripheral vasoconstriction of toes and finger’s arterioles. It might rarely affect the nose, ears, nipples, and lips.

It is characterized by recurrent attacks of triple or biphasic color changes, starting with white then followed by cyanosis and hyperemia [1,2]. These changes are reversible, which could be differentiated from other causes of irreversible damage caused by thrombosis of blood vessels or vasculitis. Patients might have neurological symptoms such as numbness and tingling, accompanied by color changes. Cold exposure is the most important predisposing factor for RP; even after slight weather changes, symptoms could occur such as moving from a hot summer day into a cold-conditioned building. Another triggering factor is emotional or mental stress through the stimulation of sympathetic nervous systems, which causes vasospasm.

The pathogenesis of RP is multifactorial and best described by the presence of vascular, neural, and intravascular abnormalities. RP is often classified clinically into primary or idiopathic RP, which is a relatively benign disease that has no adverse sequela, and usually diagnosed between ages 20 and 30. The secondary RP, which is either associated with or antedate an underlying systemic autoimmune rheumatic disease, could affect the survival based on the severity of the affected digits and the underlying disease [3,4]. RP is primarily a clinical diagnosis, but additional testing is needed to diagnose secondary RP if suspected.

The prevalence of primary RP is influenced by gender and geographical location of the study. There are many previous studies conducted in different countries exploring the prevalence of RP. The reported prevalence varies from up to 20% in females and less than 1% in males depending on definitions and selection criteria [5,6]. Still, there had been no studies done on the prevalence of Raynaud’s phenomena in the Saudi Arabia population. It was essential to know how common this phenomenon is for further patients’ education and how to avoid triggering factors and prevent more severe attacks. Thereby, this study aimed to determine the prevalence and characteristics of Saudi students with primary Raynaud’s phenomena.


Subjects and Methods

This study was conducted among medical students of Taibah University in the Western region of Saudi Arabia, AL Madinah Al munawarah, between November 2017 and April 2018. The medical faculty includes a total of 747 students both males and females. A questionnaire was used to investigate the Raynaud’s phenomena. The questionnaire was sent electronically to most of the students in the faculty, and the response rate was 40%. Medical students who fulfilled the criteria for primary Raynaud’s were included in the study.

Raynaud’s phenomena were defined based on the UK Scleroderma Study Group definition [7]. Students who had recurrent attacks of two or three color changes in the fingers or toes on cold exposure or/and mental stress were diagnosed as having RP. Students who had biphasic color changes with neurological symptoms on cold exposure considered as having severe disease. A picture, which shows the typical color changes of the hand, was added to the questionnaire to make it easy to understand. The students with underlying autoimmune rheumatic diseases or possible secondary causes for Raynaud’s phenomena were excluded.

The questionnaire included baseline demographic characteristics (such as age and gender). Other important variables were also included in the questionnaire which included the following: (1) have you ever noticed the color change of your finger on cold exposure or with stress (yes/no), if yes to which color (white/red or blue). (2) If the color changes are associated with any neurological symptoms or vasculitic skin changes. (3) How long you have fingers’ change color on cold exposure? (4) Did the changes happen in both the hands (yes/no)? And (5) have you ever called or visited your physician concerning these symptoms (yes/no)?

The data about smoking (number of daily cigarettes, for how long), caffeine use (a coffee cup per day), medical history (migraine, autoimmune disease, and irritable bowel syndrome), and drug exposure (beta-blockers and oral contraceptives use) were also included. The analysis included descriptive statistics. The Chi-square test was used in this study because it is qualitative data. The p-value was considered to be significant if p ≤ 0.05.


Results

Of 747 students in the College of Medicine at Taibah University, 300 medical students (177 female and 123 male) answered the questionnaire. None of these students had connective tissue disorders or secondary causes for RP. There were 60 (20%) of 300 students who defined color changes. Sixteen (26.9%) students reported color changes on cold weather only, 40 (64.5%) with cold weather, water, and stress, and 4 (6.6%) with stress. Of 60 students who defined color changes, 22 had the only cyanosis, 14 had redness, and eight reported blanching of the fingers. Fourteen students (4.7%) had biphasic color changes, whereas two students (0.7%) had triphasic color changes. There were a total of 16 (5.3%) students who had RP based on bi- or triphasic color changes (definite RP). Their demographic features are shown in Table 1.

The prevalence of definite RP was higher in females than males (81.2% vs. 18.8%, p = 0.05). Their mean age was as follows: 14 students between the ages of 20–30 years, whereas 2 had age <20 years. Their mean disease duration was 1–5 years for 10 students, >5 years for three students, and <1 year for three students.

There were accompanied neurological symptoms in 10 students with definite Raynaud’s phenomena which indicate more severe disease: 2 (12.5%) had only numbness, 2 (12.5%) had numbness and paresthesia, 5 (31.2%) had numbness, tingling, and paresthesia, and only 1 (6.2%) had tingling. Only one student reported seeking medical advice regarding his RP symptoms.

Smoking was reported in two students (12.4%) with RP. Caffeine consumption was more frequent in students with RP, almost 15 students (93.8%) were drinking caffeine daily (25% drinking one cup/day; however, 68.8% consume more than one cup/day). The usage of contraceptive pills was more reported in students with RP than others (25% vs. 2.5%, p = 0.003). The usage of B-blocker was not frequent among students with RP (p = 0.21). Migraine was more often reported in students with RP (p = 0.01). The frequency of irritable bowel syndrome in students with RP was not statistically significant (p = 0.061) (Table 2).


Discussion

Several studies had emphasized that the prevalence of RP varies in different populations [610]. The highest overall prevalence was reported in the USA, with a prevalence of 7.5% [11,12]. Another study from France also showed a higher prevalence of RP (11.4% in females and 2.4% in males) [13]. Harada et al. [9] reported a prevalence of 1.6% in general Japanese populations, which is the lowest prevalence worldwide.

Table 1. Baseline features of patients with definite Raynaud’s phenomena.

Variables Students with RP
(N = 16)
Students with no RP
(N = 284)
p value
Gender—female 13 (81.2%) 164 (57.7%) 0.05
Age: 20–30 years old
<20-year old
14 (87.5%)
2 (12.5%)
253 (89.1%)
26 (9.2%)
Duration of symptoms
1–5 years
<1 year
>5 years
10 (62.5%)
3 (18.8%)
3 (18.8%
-
Seeking medical advice (yes/no) 1/15 -
Associated symptoms
Numbness
2 (12.5%) -
Numbness and paresthesia 2 (12.5%) -
Numbness, tingling, and paresthesia 5 (31.2%) -
Tingling 1 (6.2%) -

Table 2. Characteristics of patients with Raynaud’s phenomena.

Students with Primary RP
Variables n (%)
Migraine 7 (43.8)
Irritable bowel syndrome 8 (50)
Smoking 2 (12.5)
Caffeine consumption (yes/no)
Number of coffee cup/day – 1 cup/day
>1 cup/ day
15/16
4 (25)
11 (68.8)
Oral contraceptive use 4 (25)
Beta-blockers 2 (12.5)

In contrast, this study showed that there was a relatively low prevalence of RP in Saudi Arabia. This study was conducted in the Western region of Saudi Arabia, where the climate is usually hot and dry. Moreover, the low prevalence of RP was found in this study, and some of the previous studies suggested that other factors could be responsible based on the use of different definitions and inclusion criteria, various types of study designs, geographical variation, and presence of certain risk factors [1417].

In addition, the effect of cold exposure and mental stress on the prevalence of RP was also observed. Moreover, the more frequent symptoms were reported with cold exposure than emotional stress. Moreover, the frequency of biphasic color changes was observed more frequently than the classic triphasic changes (4.7% vs. 0.67%, respectively). This observation was in agreement with the previous report by Onbasi et al., which includes 768 subjects and had observed the typical triphasic color changes were a rare finding to find [18].

The previous studies had reported a higher prevalence of RP in the female population [5,19]. This study showed the same female predominance. The results suggested a significant role of hormonal changes in the pathogenesis of RP. Furthermore, the use of oral contraceptive pills was more in students with RP, which supported the hypothesis of the role of estrogen in the pathogenesis of RP.

The previous studies investigated the association between smoking and Raynaud’s phenomena. The vasoconstrictive effects of cigarette smoke on peripheral blood vessels were found to be a risk factor for Raynaud’s disease [6,16,18,20,21]. Conversely, there were many other studies with conflicting results [11,13,22]. This study showed no association between smoking and RP. Only two students were smoking out of 16, which was a small number to show a significant relation.

Importantly, this study had found an association between migraine and RP. Interestingly, many previous studies reported a similar association between RP and migraine [1,2325]. Both of these conditions shared the same underlying mechanism of vasosplastic disorders and increased by exposure to stress.

Several investigators had found an association between caffeine consumption and RP [26,27]. However, the relationship is still controversial. It was found among students who had definite RP, and 11 of them were drinking more than one cup/day. Caffeine has many various effects on vascular smooth muscle cells. It could induce vasodilation because of its component xanthine that inhibits phosphodiesterase and thereby cause accumulation of cAMP. Conversely, excessive caffeine intake had been associated with peripheral vasoconstrictive effects by competitively inhibiting the action of endogenously released adenosine on blood vessels, which increases peripheral vascular resistance and causes high blood pressure and headache.

In 2012, a large meta-analysis investigated the usage of beta-blockers and RP. An association between using beta-blockers and increased incidence of RP was observed [28]. In contrast, some studies failed to show any worsening of patients’ symptoms with beta-blockers’ use [29,30]. It was found in this study that there was no relationship between beta-blockers’ use and RP. The reason for this discrepancy is not yet clear, but most of the previous studies were old and had a small sample size.

There were some limitations in this study. First, there was a small sample size, but it was in agreement with some of the previous studies which were carried out on the prevalence of RP and had a small number of patients. Second, blood tests were not done to measure ANA, and also the nailfold capillaroscopy was not used. Another limitation was that the selected population, which included medical students, could not reflect the general population.


Conclusion

The prevalence of primary RP was relatively low, but climate, genetic, and environmental factors may play a significant role. Migraine was frequent in students with Raynaud’s phenomena. An increased caffeine intake and the use of contraceptive pills were more reported with RP. Thus, a more extensive study, which includes a larger sample of the general population to address the prevalence of Raynaud’s disease, disease association, and risk factors, is recommended in future.


List of Abbreviations

ANA Antinuclear antibodies
cAMP Cyclic adenosine monophosphate
RP Raynaud’s phenomena

Conflict of interest

The authors declared that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent of publication

Informed consent was obtained from all the participants.


Ethical approval

This study was approved by the Ethics Review Committee of the university. Taibah University, College of Medicine Research Ethical Committee (Dr. Hamdi Almaramhi; chair of CM-REC), 18-12-2017, IORG0008716-IRB00010413.


Author details

Roaa Aljohani1, Halah Izzeldin Abuzaid2*, Rahaf Eid Alhazmi2, Ala Abdulrahman Sdaqir2, Soliman Masoud Amer3

  1. Rheumatologist, Systemic Lupus and Psoriatic Arthritis Consultant, Assistant Professor of Internal Medicine, Taibah University, Medina, Saudi Arabia
  2. Medical Interns, College of Medicine, Taibah University, Medina, Saudi Arabia
  3. Associate Professor Family and Community Medicine Department, College of Medicine, Taibah University, Medina, Saudi Arabia

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How to Cite this Article
Pubmed Style

Aljohani R, Abuzaid HI, Alhazmi RE, Sdaqir AA, Amer SM. Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. IJMDC. 2020; 4(3): 706-710. doi:10.24911/IJMDC.51-1578239190


Web Style

Aljohani R, Abuzaid HI, Alhazmi RE, Sdaqir AA, Amer SM. Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. http://www.ijmdc.com/?mno=80709 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1578239190


AMA (American Medical Association) Style

Aljohani R, Abuzaid HI, Alhazmi RE, Sdaqir AA, Amer SM. Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. IJMDC. 2020; 4(3): 706-710. doi:10.24911/IJMDC.51-1578239190



Vancouver/ICMJE Style

Aljohani R, Abuzaid HI, Alhazmi RE, Sdaqir AA, Amer SM. Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. IJMDC. (2020), [cited March 29, 2020]; 4(3): 706-710. doi:10.24911/IJMDC.51-1578239190



Harvard Style

Aljohani, R., Abuzaid, . H. I., Alhazmi, . R. E., Sdaqir, . A. A. & Amer, . S. M. (2020) Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. IJMDC, 4 (3), 706-710. doi:10.24911/IJMDC.51-1578239190



Turabian Style

Aljohani, Roaa, Halah Izzeldin Abuzaid, Rahaf Eid Alhazmi, Ala Abdulrahman Sdaqir, and Soliman Masoud Amer. 2020. Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 706-710. doi:10.24911/IJMDC.51-1578239190



Chicago Style

Aljohani, Roaa, Halah Izzeldin Abuzaid, Rahaf Eid Alhazmi, Ala Abdulrahman Sdaqir, and Soliman Masoud Amer. "Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 706-710. doi:10.24911/IJMDC.51-1578239190



MLA (The Modern Language Association) Style

Aljohani, Roaa, Halah Izzeldin Abuzaid, Rahaf Eid Alhazmi, Ala Abdulrahman Sdaqir, and Soliman Masoud Amer. "Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia." International Journal of Medicine in Developing Countries 4.3 (2020), 706-710. Print. doi:10.24911/IJMDC.51-1578239190



APA (American Psychological Association) Style

Aljohani, R., Abuzaid, . H. I., Alhazmi, . R. E., Sdaqir, . A. A. & Amer, . S. M. (2020) Prevalence of primary Raynaud's phenomena among healthy medical students in the Western region of Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 706-710. doi:10.24911/IJMDC.51-1578239190