A 36-year-old male presented at our clinic by early autumn for pruritus and a sudden spotted rash on the dorsum, palms and soles with no fever.

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images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 369;17 nejm.org october 24, 2013 1638A 45-year-old woman living in a rural area of northern Spain presented to our clinic with cold hands. These symptoms had developed over a period of 6 years. Raynaud's phenomenon was seen after her hands were exposed to cold. The antinuclear antibody titer was greater than 1:1280, with an anticentromere antibody pattern. This pattern may be present in 40 to 80% of patients with limited scleroderma, and secondary Raynaud's phenomenon may be seen in 80 to 90% of such patients. In 30% of patients with secondary Raynaud's phenomenon, it may be an early presentation of scleroderma. The patient's blood pressure was 135/95 mm Hg at presentation, and she had no other symptoms except skin thickening. We initiated treatment with a calcium-channel blocker. Laboratory testing during follow-up showed mild lymphopenia (1540 lymphocytes per cubic millimeter) and a creatinine level of 0.70 mg per deciliter (60 µmol per liter); the blood pressure was 120/70 mm Hg. The patient wears gloves to protect her hands in cold weather.

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