What is the treatment for chilblains?

Treatment for Chilblains

The first-line treatment for chilblains includes protective measures against cold exposure and the use of topical corticosteroids, with nifedipine as the preferred pharmacologic therapy for moderate to severe cases.

Diagnosis and Clinical Presentation

Chilblains (pernio) are localized inflammatory lesions of the skin resulting from an abnormal response to cold exposure. They typically present as:

• Erythematous, purplish, edematous lesions on acral sites (fingers, toes)
• Accompanied by pain, itching, or burning sensation
• Usually develop 12-24 hours after cold exposure
• More common in thin individuals (BMI <25th percentile) 1, 2
• More prevalent in young women, though can occur in any age group

Treatment Algorithm

1. Preventive Measures (All Cases)

• Avoid cold exposure and keep extremities warm and dry 1, 3
• Wear appropriate clothing, including warm socks and gloves
• Avoid wearing sandals or open footwear in cold weather 2
• Gradual warming of affected areas (avoid direct heat application)

2. Mild Cases

• Cold protection advice and preventive measures are often sufficient 1
• Gentle cleaning and drying of affected areas
• Topical emollients (50% white soft paraffin and 50% liquid paraffin) to support barrier function 4
• Topical high-potency corticosteroids (e.g., clobetasol 0.05% or fluocinonide 0.05%) 4

3. Moderate to Severe Cases

• Oral nifedipine (calcium channel blocker) - first-line pharmacologic therapy with moderate evidence of efficacy 5
  • Produces vasodilation
  • Reduces pain
  • Facilitates healing
  • Prevents new lesions
• Pentoxifylline as an alternative when nifedipine is contraindicated 5

4. Refractory Cases

Consider:

• Intralesional triamcinolone injections for persistent lesions 4
• Systemic corticosteroids for severe inflammation 1
• Other vasodilators like tadalafil (though evidence is limited) 5

Special Considerations

Secondary Chilblains

• Evaluate for underlying conditions when chilblains are persistent or recurrent:
  • Connective tissue diseases (especially lupus erythematosus)
  • Cryoproteins
  • Raynaud's phenomenon
  • Anorexia nervosa in children 2
  • Antiphospholipid antibodies 2, 6

Monitoring and Follow-up

• Most cases resolve spontaneously with warmer weather 1
• Monitor for secondary bacterial infection, which may require antibiotics 1
• Complete resolution typically occurs by late spring in seasonal cases

Prognosis

The prognosis for properly treated chilblains is excellent 2. Most patients improve spontaneously with warmer weather or respond well to cold protection advice and symptomatic treatment. Recurrence is common with repeated cold exposure, emphasizing the importance of preventive measures.

Common Pitfalls to Avoid

1. Failure to distinguish chilblains from Raynaud's phenomenon (which has sharper demarcation and shorter duration) 2
2. Overlooking secondary causes in recurrent or persistent cases
3. Applying direct heat to affected areas, which can worsen tissue damage
4. Delaying treatment of secondary bacterial infections
5. Inadequate patient education about preventive measures

For most patients with idiopathic chilblains, a combination of preventive measures and symptomatic treatment is sufficient, with pharmacologic therapy reserved for moderate to severe or refractory cases.