What is the management and treatment for chillblains?

Management and Treatment for Chilblains

The management of chilblains primarily involves keeping extremities warm, avoiding cold exposure, and using nifedipine for severe or refractory cases. 1, 2

Understanding Chilblains

Chilblains (also known as pernio) are localized inflammatory lesions of the skin resulting from an abnormal response to cold but non-freezing temperatures. They typically present as:

• Erythematous, purplish, edematous lesions that appear 12-24 hours after cold exposure 3
• Accompanied by intense pain, itching, or burning sensations 3
• Most commonly affecting acral sites (fingers, toes, ears, nose) 1
• More prevalent in thin individuals and young women 3

First-Line Management

Preventive Measures

• Avoid cold exposure - the most important preventive strategy 1
• Keep extremities warm with appropriate clothing (gloves, warm socks, proper footwear) 1
• Smoking cessation is strongly recommended as it contributes to vasospasm 1
• Avoid wearing sandals or inadequate footwear during cold weather 3

Initial Treatment

For acute chilblains, implement the following measures:

• Clean and dry the affected area 4
• Gradual rewarming of the affected limb 3
• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin to affected areas 5
• Avoid further cold exposure to prevent recurrence or chronic chilblains 3

Pharmacological Treatment

For persistent or severe chilblains that don't respond to preventive measures:

First-Line Medication

• Nifedipine (calcium channel blocker): Most evaluated treatment with moderate evidence of effectiveness 1, 2
  • Produces vasodilation
  • Reduces pain
  • Facilitates healing
  • Prevents new lesions 3

Alternative Medications

• Pentoxifylline: Moderate evidence supporting use in severe or refractory cases 2
• Topical corticosteroids (e.g., betamethasone): Commonly used but effectiveness not confirmed in randomized trials 1
• Other options with limited evidence:
  • Hydroxychloroquine 1
  • Topical nitroglycerin 1
  • Diltiazem 2

Special Considerations

Chilblain Lupus Erythematosus

If chilblains persist or are associated with other symptoms, consider chilblain lupus erythematosus, which may require:

• Antimalarial agents
• Prednisone
• Pentoxifylline
• Dapsone 6

Evaluation for Underlying Conditions

• Screen for systemic symptoms and autoimmune diseases 1
• Consider laboratory evaluation including antinuclear antibody profile 3
• Rule out cryoproteins, Raynaud's phenomenon, and frostbite 3, 6

Prognosis

The prognosis for properly treated chilblains is excellent 3. Most cases are self-limited and resolve spontaneously with warming of the weather, though they may recur seasonally 1.

Common Pitfalls to Avoid

• Misdiagnosis: Chilblains can be confused with Raynaud's phenomenon (which has shorter duration episodes) or frostbite (which involves tissue freezing) 3
• Inadequate prevention: Failing to emphasize preventive measures can lead to recurrence 1
• Overlooking underlying conditions: Not screening for predisposing factors like anorexia nervosa in children or systemic lupus erythematosus in adults 3
• Delayed treatment: Not initiating pharmacological therapy for severe or persistent cases 2