Chilblain

1 - ACKNOWLEDGEMENTS

Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology

2 - OVERVIEW

Chilblains are itchy or tender, red or purple, bumps, spots or swellings on the skin that occur in response to repeated exposure to cold.

Chilblains are also known as pernio or perniosis, and are most common among individuals who live in cold climates. Symptoms commonly begin in early winter and resolve by spring as cold exposure decreases. However, patients may have recurrences seasonally for years.

Chilblains are more common in women, children, and the elderly. Elderly patients may have a prolonged course, while younger patients improve spontaneously. Being underweight may also be a risk factor for chilblains.

Chilblains can be uncomfortable, but rarely cause permanent damage. Lesions often heal within a few weeks if further exposure to the cold is avoided.

3 - SYMPTOMS

Chilblains usually appear as single or multiple, red, purple or dark blue, patches or bumps on the skin. The most common locations are the toes and fingers, and less often the heels, nose, and ear. The affected skin may also swell, and symptoms of burning and itching are often present. In severe cases, blistering or skin ulcers may be seen. Skin infection is a potential complication in these severe cases.

Chilblains appear after cold exposure, with the greatest severity of symptoms occurring during cold months of the year. The lesions resolve on their own within few weeks if further exposure to the cold is avoided. Persistence of chilblains beyond the cold seasons occasionally occurs but, in these cases, patients should seek medical care to rule out other medical conditions.

4 - CAUSES

Doctors do not know the precise mechanism that causes chilblains. The condition is thought to represent an abnormal inflammation of the small blood vessels in the skin that occur in response to repeated exposure to cold. The cold makes the tiny blood vessels in the skin of fingers and toes get smaller. This stops blood moving around as easily. If the skin is then exposed to heat, the blood vessels become wider and blood rushes quickly to the fingers and toes. This can cause the leak of the blood vessels and inflammation, resulting in pain, redness and swelling.

Factors that may increase the risk of chilblains include female sex, patients with poor circulation, low body weight, a family history of chilblains and regular exposure to cold, damp or draughty conditions.

The development of chilblains has been reported in patients with blood disorders, autoimmune diseases and viral hepatitis. However, there is no sufficient information to confirm a relationship between chilblains and the reported diseases. Lupus is the most common autoimmune disorder associated with chilblains. In these cases, patients with clinical or laboratory alterations of lupus developed skin lesions that are compatible with chilblains.

5 - TREATMENT

To prevent chilblains is important to avoid or limit the exposure to cold, damp conditions and use adequate clothing. Patients should dress in layers of loose clothing, and cover all exposed skin as completely as possible when going outside in cold weather. If the skin is exposed to cold, it is important to rewarm it gradually, because sudden rewarming of cold skin may worsen chilblains. Patients who smoke should be encouraged to discontinue smoking, because nicotine can cause constriction of blood vessels and worsen chilblains.

The patients should keep the affected area warm and dry by wearing appropriately insulated clothing, gloves, and footwear. The patients could take analgesic medications, including paracetamol or ibuprofen, to relief the symptoms of pain or burning. It is also important to moisturize the skin of the hands and feet and avoid scratching the lesions.

If the patients do not improve with these interventions, there are some pharmacologic treatments that can help. Steroid ointments or creams and nifedipine pills are among the most commonly used therapies.

— Steroid ointments or creams could be apply on the lesions – these medicines help to reduce inflammation and itching. However, it is possible that this medication does not shorten the duration of the chilblains.

— Nifedipine pills – is a medicine known as a calcium channel blocker, and it is commonly used in patients with elevated blood pressure. Nifedipine may help to treat chilblains by opening wide the small blood vessels and improving circulation. Nifedipine may also be used to prevent chilblains in the winter months in people who have repeated and severe symptoms.

6 - TIPS FOR MANAGING

In most cases, chilblains will get better on their own within few weeks. It is important to see a doctor if the chilblains do not improve after two to three weeks, if the symptoms are severe and recurrent, if there are signs of infection (swelling and pus coming out of the affected area, fever, feeling unwell or shivering), or if the chilblains persist into the warm months.

The management of chilblains should focus in measures to minimize cold exposure. Patients should wear appropriately insulated clothing and avoid cold breezes or cold places.

If the patients do not improve with these measures, treatment with nifedipine pills or steroid ointments or creams could be used.