Chilblains

Published on 19/03/2015 by admin

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Last modified 19/03/2015

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Chilblains

Antonios Kanelleas and John Berth-Jones

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

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Chilblains (also called perniosis) are localized, inflammatory, erythematous lesions that are caused by exposure to cold ambient temperatures above freezing point. High humidity and wind, which exacerbate conductive heat loss, also play a significant part. They are thought to be caused by a persistent vasoconstriction of the deep cutaneous arterioles with accompanying dilatation of the small superficial vessels. The onset is usually in the autumn or winter. Chilblains are more common in temperate climates, when winters get rather cold and damp and people are not used to these conditions. Lesions occur acutely as single or multiple erythematous or dusky swellings that may occasionally ulcerate or blister. They are usually accompanied by pruritus or a burning sensation. Sites of predilection are the fingers, toes, heels, lower legs, thighs, nose, and ears. A specific subset occurs on the thighs of patients wearing tight-fitting, poorly insulating trousers (e.g., as worn by young horsewomen). Perniosis can also be a manifestation of eating disorders (anorexia nervosa, poor nutrition), and systemic diseases (lupus erythematosus and hematological malignancies).

Management strategy

The most important aspect is prophylaxis. This will be achieved through the use of warm clothing and warm, properly insulated housing. Avoidance of exposure in cold weather is, obviously, equally important. Once chilblains occur, they usually run a self-limiting course over a period of a few weeks. Treatment includes rest in a warm environment and possibly topical antipruritics, if needed. Vasodilator calcium channel blockers (nifedipine 20–60 mg daily, diltiazem 60–120 mg three times daily) have been shown to be an effective therapy and preventative measure in patients with idiopathic acral perniosis, and in those patients with perniosis associated with low body weight. Appropriate investigation to exclude myeloproliferative disorders, connective tissue diseases, and eating disorders is required. Particularly in children, chilblains have been linked with cold-sensitive dysproteinemia. In elderly patients and those with ulcerative lesions, peripheral vascular insufficiency must be excluded. The condition must be distinguished from chilblain lupus erythematosus (LE). The latter is a form of cutaneous LE manifesting with lesions resembling chilblains. Lesions develop in cold weather but tend to persist and ulcerate. Chilblain LE may be accompanied by discoid LE. Up to 20% of patients with chilblain LE will develop systemic LE.

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