What is the treatment for chilblains?

Treatment of Chilblains (Pernio)

For idiopathic chilblains, begin with cold avoidance and warming measures as first-line management, and when pharmacologic therapy is needed for severe or refractory cases, use oral nifedipine as the evidence-supported first-line medication. 1

Initial Management: Non-Pharmacologic Measures

• Avoid cold exposure and keep extremities warm - this is the most important first recommendation for all patients with chilblains 2
• Clean and dry the affected limb, then rewarm gradually (not rapidly) 3
• Smoking cessation is essential if the patient smokes, as tobacco worsens vasospasm 2
• Prevention is the best therapy after initial presentation - minimize cold exposure to prevent recurrence 3

When to Initiate Pharmacologic Treatment

Most chilblains resolve spontaneously with warmer weather and conservative measures alone 4. Consider medication for:

• Severe symptoms (intense pain, significant functional impairment) 1
• Refractory cases not responding to warming measures 1
• Recurrent episodes despite preventive measures 2

First-Line Pharmacologic Therapy

Nifedipine (calcium channel blocker) has moderate evidence as the most evaluated treatment for chilblains 1:

• Produces vasodilation that reduces pain, facilitates healing, and prevents new lesions 3
• Important caveat: Effectiveness is not confirmed by all studies - some trials show benefit while others do not 2
• Despite mixed evidence, nifedipine remains the most studied and recommended first-line agent when medication is warranted 2, 1

Second-Line Pharmacologic Options

If nifedipine is ineffective or contraindicated, consider:

• Pentoxifylline - has moderate evidence for severe or refractory cases 1
• Topical betamethasone - commonly used but effectiveness not confirmed by randomized trials 2
• Other agents with limited evidence: topical nitroglycerin, hydrochloroquine, tadalafil, topical minoxidil 2, 1

Symptomatic Management

• NSAIDs for pain control 4
• Oral prednisolone may be used for acute severe symptoms, though evidence is limited to case series 4

Essential Evaluation to Rule Out Secondary Causes

Before diagnosing idiopathic chilblains, screen for underlying conditions:

• Obtain antinuclear antibody (ANA) profile to exclude systemic lupus erythematosus and other connective tissue diseases 3, 5
• Screen for systemic symptoms suggesting autoimmune disease 2
• Consider testing for cryoproteins, cryoglobulinemia, antiphospholipid antibodies, and monoclonal gammopathy in adults with atypical presentations 3, 5
• In children, assess for anorexia nervosa or thin body habitus (BMI <25th percentile), which predisposes to chilblains 3

Expected Clinical Course and Follow-Up

• Acute chilblains typically develop 12-24 hours after cold exposure 3
• Most cases resolve completely by late spring (November in Southern Hemisphere) with conservative management alone 4
• Prognosis for properly treated chilblains is excellent 3
• Watch for secondary bacterial infection requiring hospitalization in severe cases 4

Key Clinical Pitfalls to Avoid

• Do not confuse with Raynaud's phenomenon - Raynaud's has sharply demarcated pallor/cyanosis lasting hours, while chilblains persist for days 3
• Do not confuse with frostbite - frostbite involves actual tissue freezing and necrosis, not just cold exposure 3
• Recognize that chilblains may be more common than previously thought, particularly during unusually cold winters even in warmer climates 4, 5
• Prompt recognition avoids excessive investigation and patient anxiety - most patients are systemically well and need only symptomatic treatment 4