raynaud phenomenon is a common health problem characterized by episodic cyanosis , swelling , and pallor on both upper and lower extremities with cold exposure . this group of disorders predominantly affects females . in the history of this disorder , researches have described many etiologic factors , but , to date , neither an objective , quantitative diagnostic tool , nor an objective follow - up method has been defined . in this study , we aimed to find an optimized method for the follow - up of patients with raynaud phenomenon . in this retrospective study , we aimed to describe an optimized method for the follow - up of patients with raynaud phenomenon , and to compare its efficacy with a verbal complaint severity scale . our local ethics committee approved the study ( ethics approval number 1291 ) . between august 2012 and july 2013 , data of 81 patients with raynaud phenomenon symptomatology were collected . systemic evaluation including blood examinations , capillaroscopy , and doppler ultrasonography demographic data , concomitant disorders ( such as hypertension , diabetes mellitus , renal insufficiency , and thoracic outlet syndromes ) , and type and duration of symptoms were recorded . in our center , therefore , we routinely apply the cold stimulation test ( cst ) to all of our patients presenting with the raynaud phenomenon symptomatology . all patients are only allowed to wear their shirts , without additional jackets or coats throughout the test . all measurements of cst are performed with the patient s hand at the level of the heart . a sonatemp 400/700 monitor ( sheridan catheter corp . hand temperatures of the patients are measured with a probe , which is inserted between the pulp of the first and second distal phalanges . the most affected extremity is immersed into the + 4c iced - water for 20 seconds . , the fingertip temperature is measured again at 5 , 10 , 15 and 20 minutes , with the same technique as detailed before . the assessment scale for cst is given in table 1 . in order to evaluate the effectiveness of the medical treatment , we routinely use a verbal complaint severity scale ( vcss ) described in our previous study . according to our clinical protocol , we routinely use the combination of pentoxifylline 1200 mg / d bid ( 2600 mg ) as a vasodilator molecule , nifedipine 60 mg / d bid ( 230 mg ) as a calcium - channel blocker , and acetylsalicylic acid 300 mg / d ( 1300 mg ) as an antiplatelet agent . beside these medications , all of the patients are advised to protect themselves from cold as much as possible . spss for mac 20.0 package program ( spss inc , chicago , il ) was used for statistical evaluation . descriptive results were expressed as mean  standard deviation for normally distributed continuous variables and median values for abnormally distributed continuous variables . comparisons of the parametric values were performed with the t - test for normally distributed groups and with mann - whitney u test and wilcoxon signed ranks test with abnormally distributed groups . pearson s chi - square test , fisher s exact test , and mcnemar - bowker test were used for the comparisons of categorical variables . a p value of < 0.05 was considered as statistically significant with a 95% confidence interval . between august 2012 and july 2013 , data of 81 patients with raynaud phenomenon symptomatology were collected . systemic evaluation including blood examinations , capillaroscopy , and doppler ultrasonography demographic data , concomitant disorders ( such as hypertension , diabetes mellitus , renal insufficiency , and thoracic outlet syndromes ) , and type and duration of symptoms were recorded . in our center , testing of patients response to cold stimulation is mandatory due to our national regulations . therefore , we routinely apply the cold stimulation test ( cst ) to all of our patients presenting with the raynaud phenomenon symptomatology . all patients are only allowed to wear their shirts , without additional jackets or coats throughout the test . all measurements of cst are performed with the patient s hand at the level of the heart . hand temperatures of the patients are measured with a probe , which is inserted between the pulp of the first and second distal phalanges . the most affected extremity is immersed into the + 4c iced - water for 20 seconds . the fingertip temperature is measured again at 5 , 10 , 15 and 20 minutes , with the same technique as detailed before . we recently defined an assessment scale of cst in our previous paper . the assessment scale for cst is given in table 1 . in order to evaluate the effectiveness of the medical treatment , we routinely use a verbal complaint severity scale ( vcss ) described in our previous study . according to our clinical protocol , we routinely use the combination of pentoxifylline 1200 mg / d bid ( 2600 mg ) as a vasodilator molecule , nifedipine 60 mg / d bid ( 230 mg ) as a calcium - channel blocker , and acetylsalicylic acid 300 mg / d ( 1300 mg ) as an antiplatelet agent . beside these medications , all of the patients are advised to protect themselves from cold as much as possible . spss for mac 20.0 package program ( spss inc , chicago , il ) was used for statistical evaluation . descriptive results were expressed as mean  standard deviation for normally distributed continuous variables and median values for abnormally distributed continuous variables . comparisons of the parametric values were performed with the t - test for normally distributed groups and with mann - whitney u test and wilcoxon signed ranks test with abnormally distributed groups . pearson s chi - square test , fisher s exact test , and mcnemar - bowker test were used for the comparisons of categorical variables . a p value of < 0.05 was considered as statistically significant with a 95% confidence interval . since this study was performed in a military hospital , all of the patients were young males ; 56 out of 81 patients ( 69.1% ) are heavy smokers ( 17 patients > 10 years ) . cold - aggravated cyanosis ( 66 patients , 81.4% ) , coldness ( 50 patients , 61.7% ) , and numbness ( 47 patients , 58% ) were the most frequent symptoms . the other complaints were as following : hyperhidrosis ( 45 patients , 55.5% ) , cold aggravated swelling ( 32 patients , 39.5% ) , burning sensation ( 19 patients , 23.4% ) and pain ( 9 patients , 11.1% ) ; 57 of patients ( 70.1% ) had 3 or more complaints mentioned before , while only 1 patient had all complaints above . 11 patients were in vcss i , 32 patients were in vcss ii , and 38 patients were in vcss iii . after the treatment , when those patients were questioned again , there were no statistically significant differences between before and after treatment vcss . however , 4 patients changed their scores after the treatment . one patient in vcss i declared as vcss ii and 3 patients in vcss iii declared as vcss ii . there was a significant decrease in hand temperatures after cold exposure in both pre - treatment and post - treatment periods . pre - treatment parabola appeared to have a concave curve , which means that the temperature increased gradually . post - treatment parabola appeared like a convex curve , which means that temperature increased quickly , and continued almost at this level . there were statistically significant differences between pre - treatment and post - treatment hand temperatures at each measurement ( p<0.001 ) except initial values ( p>0.05 ) . when the results of cst for every measurement time point were separately analyzed , the following results were found : at 5 minute measurements , there was 4.02.9c increase when compared to pre - treatment values ( p<0.001 ) . at 10 minute measurements , there was 6.93.1c increase when compared to pre - treatment values ( p<0.001 ) . at 15 minute measurements , there was 5.93.4c increase when compared to pre - treatment values ( p<0.001 ) . at 20 minute measurements , there was 3.23.3c increase when compared to pre - treatment values ( p<0.001 ) . in addition , there was a 7.24.4 minutes decrease in rewarming time to initial temperature at post - treatment period compared with pre - treatment values , which was also statistically significant ( p<0.001 ) . a comparison of rewarming times at pre - treatment and post - treatment periods is given in table 4 . according to assessment scale of cst results , the distribution of included patients in the present study is given in table 5 . since this study was performed in a military hospital , all of the patients were young males ; 56 out of 81 patients ( 69.1% ) are heavy smokers ( 17 patients > 10 years ) . cold - aggravated cyanosis ( 66 patients , 81.4% ) , coldness ( 50 patients , 61.7% ) , and numbness ( 47 patients , 58% ) were the most frequent symptoms . the other complaints were as following : hyperhidrosis ( 45 patients , 55.5% ) , cold aggravated swelling ( 32 patients , 39.5% ) , burning sensation ( 19 patients , 23.4% ) and pain ( 9 patients , 11.1% ) ; 57 of patients ( 70.1% ) had 3 or more complaints mentioned before , while only 1 patient had all complaints above . 11 patients were in vcss i , 32 patients were in vcss ii , and 38 patients were in vcss iii . after the treatment , when those patients were questioned again , there were no statistically significant differences between before and after treatment vcss . however , 4 patients changed their scores after the treatment . one patient in vcss i declared as vcss ii and 3 patients in vcss iii declared as vcss ii . there was a significant decrease in hand temperatures after cold exposure in both pre - treatment and post - treatment periods . pre - treatment parabola appeared to have a concave curve , which means that the temperature increased gradually . post - treatment parabola appeared like a convex curve , which means that temperature increased quickly , and continued almost at this level . there were statistically significant differences between pre - treatment and post - treatment hand temperatures at each measurement ( p<0.001 ) except initial values ( p>0.05 ) . when the results of cst for every measurement time point were separately analyzed , the following results were found : at 5 minute measurements , there was 4.02.9c increase when compared to pre - treatment values ( p<0.001 ) . at 10 minute measurements , there was 6.93.1c increase when compared to pre - treatment values ( p<0.001 ) . at 15 minute measurements , there was 5.93.4c increase when compared to pre - treatment values ( p<0.001 ) . at 20 minute measurements , there was 3.23.3c increase when compared to pre - treatment values ( p<0.001 ) . in addition , there was a 7.24.4 minutes decrease in rewarming time to initial temperature at post - treatment period compared with pre - treatment values , which was also statistically significant ( p<0.001 ) . a comparison of rewarming times at pre - treatment and post - treatment periods is given in table 4 . according to assessment scale of cst results , since the first description of raynaud phenomenon , several diagnostic tools and treatment methods have been used . however , neither a definitive diagnostic tool nor an obvious curative treatment method has been defined , primarily due to the complex etiopathogenesis , which is still not understood completely . the second cause of this diagnostic problem may be the subjectivity of patients symptoms . most rp patients complain about cyanosis and numbness , which is often aggravated with cold exposure . these symptoms are quite inadequate for definitive diagnosis , but secondary forms of this disorder , mostly based on an underlying disease , can be diagnosed with more objective tests . in this respect , several diagnostic tools for definitive diagnosis have been defined : observation of triphasic color changes of hands and fingers , measurement of finger systolic blood pressure or finger - brachial index , plethysmography , capillaroscopy , doppler ultrasonography , and , rarely , more invasive techniques such as arteriography . most of these tools require special conditions , such as special technicians , devices , and sometimes laboratory conditions . however , even though they could be performed once for diagnosis , none of them could be used for follow - up , because of the above - mentioned features . in addition to these problems , assessment of treatment efficacy in the follow - up period is the other important problem , which also mainly depends on subjectivity of patients and their symptoms . most patients consider that all treatment modalities , independent of their types , are ineffective . however , if we could find a user - friendly , objective test to follow up these patients , we can evaluate their progress and document it ; then we can convince the patients about the progress of their status . in our study we used verbal complaint severity scale ( vcss ) for patient self - expressed feelings , such as their ideas about the treatment efficacy and the progress of the disease ; 11 patients were categorized in vcss i at pre - treatment and 10 patients were categorized in vcss i after treatment . thus , it seems that 1 of these 11 patients probably thought that their complaint became worse in the follow - up period . however , 3 patients in vcss iii before treatment were categorized in vcss ii after treatment , which probably means that their symptoms improved with treatment , but none of these changes were statistically significant and none were quantitative , obvious , and re - measurable . in this regard , cst seems to be helpful for quantitative and objective follow - up of patients with rp . in our study the quantitative data of cst such as temperature changes and decreases in rewarming time were statistically significant . when we analyzed these parameters of cst , besides the accuracy of our test , we also observed variable patterns of rewarming and rewarming time . following a decrease in hand temperature after the cold stimulation , we observed significant differences in rewarming patterns between the 2 groups ( figure 1 ) . the concave curve of pre - treatment figures in the rewarming period shows that the temperature increases slowly at the beginning , then there was a gradually increase in rewarming rate , which suggests that vasospasm lasts longer . in contrast , the convex curve of post - treatment figures in the rewarming period shows that the temperature increased quickly at the beginning , and then reached initial temperature slowly , which suggests that vasospasm duration was shorter than in the former period . when our results were analyzed and compared objectively , there were 2 parameters that can be used for follow - up of patients . one of them is patients verbal complaint severity scale and the other is the result of cst . we analyzed data from the 4 patients who had changed their verbal complaint severity scale after treatment as a subgroup , and we compared their cst results independent from the study group . in paired correlations , we found that there were no statistically significant differences between measured temperatures or rewarming times before and after treatment ( p>0.05 ) . we also found that there were no statistically significant differences in the other remaining patients who considered that no improvement was observed within the treatment protocol ( p>0.05 ) . these results mean that if the follow - up period assessment depends only on  patients expression  , researchers would have to reach a conclusion about treatment ( positive or negative ) ; however , these results would be far from real conclusions . , the cold stimulation test can be used as an objective and quantitative test , especially for follow - up of patients under treatment when it is performed with certain criteria like in our study . second , although the patients have expressed that there is no change after treatment , the study results revealed that the treatment were objectively effective . although more extensive studies are necessary , based on our results , we conclude that cst with certain criteria seems to be a much more objective , quantitative , easy to use , and scientific method than patients self - expression  for follow - up of patients with rp , regardless of treatment methods . this study was performed in a military hospital ; therefore , all of the patients were male . for this reason , it may be difficult to make a generalized conclusion for both sexes from these results . this study was performed in a military hospital ; therefore , all of the patients were male . for this reason , it may be difficult to make a generalized conclusion for both sexes from these results .