Dear Doctors: I have problems with circulation in my hands. I came across information about something called Raynaud's phenomenon and want to know if that is happening to me. Where does one go to get the nail fold test that was mentioned? My rheumatologist does not do it.

Dear Reader: Raynaud’s phenomenon is an episodic circulatory condition. The small arteries that bring blood to the extremities suddenly contract. Also known as Raynaud's syndrome, the condition typically affects the fingers, but it can happen in toes as well. Cold temperatures trigger these spasms. They may also be a response to stress. The spasms make these vessels narrow enough to reduce or even temporarily stop blood flow to the area. This also affects flow to smaller blood vessels downstream.

This sudden loss of blood flow to the extremities often causes a feeling of numbness. It also makes the affected tissue turn white, or sometimes bluish-purple. When an episode is over, blood flow returns. The skin then often turns red. The person may experience a throbbing pins-and-needles feeling. In severe cases, the repeated loss of blood flow can cause sores to form on the fingers or toes. And while rare, it is possible for the repeated spasms to lead to tissue death.

Raynaud’s phenomenon falls into two categories of diagnosis. When there is no known cause, it is known as primary Raynaud's. This is the most common form. It typically arises between the ages of 15 and 25. When Raynaud's is linked to another disease or condition, it is known as secondary Raynaud's.

Secondary Raynaud's is often a sign of an underlying autoimmune or connective tissue disorder. These can include lupus, scleroderma and rheumatoid arthritis. Thyroid disorders, certain blood disorders and pulmonary hypertension can also play a role. Secondary Raynaud's has also been linked to physical damage to the affected tissues, as can occur due to repetitive actions, exposure to chemicals, the adverse effect of certain medications or medical treatments, and hand or foot injuries.

Because the presence of Raynaud's phenomenon can signal an underlying condition or illness, it is important to get an accurate diagnosis. This can be done with a nailfold capillaroscopy, the test you are asking about. It’s a microscopic look at the tiny capillaries at the base of the fingernail. The capillaries lie flat here and are easier to see. In primary Raynaud's, the vessels will appear normal. But because secondary Raynaud's arises from vascular injury due to an underlying disease, these vessels will show signs of structural damage.

Nailfold capillaroscopy is not a routine in-office test. As a result, many doctors, like your own, do not offer it. The test requires special magnification equipment and training to interpret the findings accurately. Look for a rheumatologist who specializes in connective tissue disease or a dermatologist with an interest in vascular or autoimmune skin disease. You’ll most likely find this test available at a large medical center, university hospital or specialty clinic with a focus in these diseases.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: My 31-year-old daughter has leg cramps, fatigue and brain fog. Her apartment tested positive for mold, and she was told she has CIRS. She started a treatment called the Shoemaker protocol. Are either of those medically recognized? Might other causes or cures be overlooked?

Dear Reader: Your daughter has been diagnosed with what some clinicians refer to as chronic inflammatory response syndrome, often called CIRS. Proponents of the diagnosis describe it as a systemic inflammation that involves multiple organ systems. They believe it’s an immune system response to exposure to mold, fungi or other toxins in the environment. This exposure can often occur in water-damaged buildings. However, CIRS is not widely seen as an established medical diagnosis. Almost everything about it remains the subject of research and ongoing debate. This includes the criteria for diagnosis, biomarkers and ways to treat it.

There is clear agreement on one point: Molds and other forms of fungal growth can pose serious health risks. This is particularly true when their growth is extensive or there’s long-standing exposure. Symptoms often vary a lot from person to person. This can make it hard to identify a mold-related illness. Symptoms can include nasal congestion; sore throat; and red, watery or itchy eyes. Respiratory symptoms include tight chest, wheezing and difficulty breathing. Skin symptoms include irritation like a rash or dermatitis. Even headache and fatigue can be symptoms.

Another challenge with mold-related illness is effective treatment. Fungi are more closely related to humans than bacteria. That makes it hard to develop drugs that can eliminate fungi without harming human cells. A few antifungal medications do exist. Often their use is limited to specific fungal infections. Many chronic or environmental illnesses from mold exposure rely on removing the source of exposure. Then it’s about managing symptoms, usually not relying solely on antifungal medications.

This gap in available treatments has opened the door to treatments like the Shoemaker protocol. It’s a multi-step approach that starts with testing for mold or moisture problems. Test results may signal exposure to fungal toxins. Then, it focuses on removing sources of exposure. The patient can be tested for certain biomarkers that are believed to signal the presence of CIRS. Then there’s a course of off-label treatment with medications. The idea is the medications bind to toxins so they can be excreted in the stool.

The Shoemaker protocol is as disputed as the syndrome it is meant to treat. One concern is that a focus on CIRS may delay other diagnoses. Other causes could be missed. In a more conventional medical path, a doctor would explore other causes for your daughter’s symptoms. These could include endocrine disorders, vitamin deficiencies, electrolyte imbalance, central nervous system disorders and peripheral neuropathies. Undiagnosed asthma, Lyme disease, sleep disorder and autoimmune conditions could also be checked. If your daughter's current approach doesn't bring relief, consider encouraging her to seek a broader medical evaluation.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

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Dear Doctors: Intense pain during a bowel movement sent our son to the ER. He got diagnosed with a blood clot in a hemorrhoid and needed surgery to fix it. I thought hemorrhoids happen when you sit a lot. Our son is a football player, so it's a big surprise that he even had them.

Dear Reader: Your son had a condition known as a thrombosed hemorrhoid. That's the medical term for a blood clot that develops inside of a hemorrhoid. This can range from a mild problem that can be managed with home remedies to the very painful emergency your son had. To understand what happened, we should begin with the site of the problem: the hemorrhoid.

The tissues of the lower bowel are served by a rich supply of blood vessels. These include veins, arteries and capillaries. These support the complex functions needed for elimination. Pressure on the veins in the rectum or the anus can cause them to swell. At the same time, the connective tissue that supports these blood vessels can get weak. The result is a bulging vein, known as a hemorrhoid. In some cases, blood can pool in the swollen vessel, raising the risk of a clot. This is a thrombosed hemorrhoid. It’s most often seen with external hemorrhoids. However, it can occur internally as well.

Prolonged sitting can lead to hemorrhoids. Repeated straining during a bowel movement can also be a cause. Other causes are pregnancy, obesity and not getting enough fiber. The natural weakening of tissues that comes with advancing age can also be a factor. Heavy lifting, including the weight training athletes do to increase strength and bulk, may also contribute. It can increase the intra-abdominal pressure that causes hemorrhoids to develop.

The surgery that your son underwent is a hemorrhoid excision. The sudden, intense and unrelenting pain caused by the clot is likely why surgery was needed. This surgery is typically done under local anesthesia. The doctor removes the clot through a cut in the surface of the hemorrhoid. They usually identify the site of the clot visually, or by gently palpating the swollen tissues. Removing the clot instantly relieves internal pressure and eases the pain. Patients often return home the same day. They are usually given instructions to take a daily sitz bath to keep the surgical site clean and moist. The incision should mostly heal within a week.

In most cases, swelling and discomfort improve after a few days. Some people find that a mild pain medication helps them while they heal. It is important to keep bowel movements soft as the area heals. That means drinking plenty of fluids and including plenty of fiber in the diet. It’s also vital to avoid too much sitting, abdominal straining and any heavy lifting during recovery. When the factors that caused the thrombosed hemorrhoid are adequately addressed, recurrence is rare.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)