What is the treatment for chillblains?

Treatment of Chilblains (Pernio)

For idiopathic chilblains, cold avoidance and protective measures are first-line management, with oral nifedipine (typically 20 mg three times daily) as the most evidence-based pharmacologic option for severe or refractory cases, though its effectiveness remains inconsistent across studies. 1, 2

Initial Management: Non-Pharmacologic Measures

Cold protection is the cornerstone of treatment and prevention:

• Avoid cold exposure and keep extremities warm with appropriate clothing (gloves, warm socks, insulated footwear) 1, 3
• Gradual rewarming is essential—never rewarm extremities suddenly after cold exposure, as rapid warming causes vasospasm and worsens the condition 4
• Smoking cessation is strongly recommended, as smoking exacerbates vasospasm 1
• Clean and dry the affected limb thoroughly 3

Common pitfall: Patients often try to rapidly warm cold extremities (e.g., placing hands directly on a heater), which paradoxically worsens symptoms through vasospasm. Emphasize gradual, gentle rewarming. 4

Pharmacologic Treatment Options

First-Line: Calcium Channel Blockers

Nifedipine is the most studied and recommended pharmacologic treatment:

• Nifedipine produces vasodilation and has been demonstrated to reduce pain, facilitate healing, and prevent new lesions 3
• A systematic review found moderate evidence supporting nifedipine for severe or refractory idiopathic chilblains 2
• However, effectiveness is not confirmed by all studies—the evidence remains mixed 1
• Typical dosing: 20 mg three times daily (though specific dosing should follow standard nifedipine protocols)

Important caveat: While nifedipine is the most evaluated treatment, its inconsistent efficacy across studies means some patients may not respond. 1, 2

Second-Line Options

Pentoxifylline has moderate evidence for severe or refractory cases 2, though fewer studies support its use compared to nifedipine 1

Topical corticosteroids (particularly betamethasone) are commonly used in clinical practice, but their effectiveness has not been confirmed by randomized clinical trials 1

Limited Evidence Treatments

The following have shown benefit only in small numbers of patients:

• Topical nitroglycerin 1
• Hydrochloroquine 1
• Diltiazem 2
• Vitamin D 2

Acupuncture appears to provide some benefit based on limited data 1

Clinical Evaluation

Screen for secondary causes before diagnosing idiopathic chilblains:

• Check for systemic symptoms and underlying autoimmune disease 1
• Laboratory evaluation should include antinuclear antibody profile to exclude systemic lupus erythematosus 3
• Screen for cryoproteins and antiphospholipid antibodies in appropriate clinical contexts 3
• Consider anorexia nervosa in thin adolescents, as low BMI (<25th percentile) is a risk factor 3, 5

Skin biopsy can be useful in dubious cases, showing dermal edema and inflammatory infiltrate particularly around eccrine glands 1

Natural History and Prognosis

• Acute pernio typically develops 12-24 hours after cold exposure 3
• Lesions usually begin in fall/winter and spontaneously resolve in spring or early summer 1, 3
• Most patients improve with warmer weather or cold protection advice alone 5
• The prognosis for properly treated pernio is excellent 3

Reassurance is important: Chilblains are almost always benign, patients are systemically well, and most need only symptomatic treatment. Prompt recognition avoids excessive investigation and anxiety. 5

Treatment Algorithm

1. All patients: Cold avoidance, protective clothing, gradual rewarming, smoking cessation
2. Mild cases: Observation with non-pharmacologic measures; consider topical corticosteroids (though unproven)
3. Moderate-to-severe or refractory cases: Add oral nifedipine
4. Non-responders to nifedipine: Consider pentoxifylline as alternative
5. Persistent cases: Re-evaluate for secondary causes; consider referral to rheumatology or dermatology

Special consideration for adolescents: Thin body habitus increases risk—counsel on adequate clothing and avoiding fashion choices that expose extremities to cold (e.g., wearing sandals in winter). 3, 5