What is the treatment for chilblains on toes?

Treatment of Chilblains on Toes

The primary treatment for chilblains on toes is prevention through cold avoidance and gradual rewarming, with nifedipine being the most evidence-supported pharmacological option when symptoms are severe or recurrent. 1, 2

Immediate Management

Cold Exposure Management

• Avoid sudden rewarming of affected extremities, as rapid temperature changes cause vasospasm and worsen the condition 3
• Clean and dry the involved limb, then rewarm gradually 2
• Remove from cold, damp environments immediately 1

Symptomatic Relief

• Topical betamethasone (corticosteroid ointment) is commonly used for symptomatic relief, though its effectiveness lacks confirmation from randomized trials 1
• Antihistamines may be prescribed for severe itching when needed 3

Preventive Measures (Essential First-Line Approach)

Prevention is the best form of therapy and should be emphasized to all patients. 2

Cold Protection Strategies

• Wear warm socks and gloves to protect acral parts from cold exposure 3
• Avoid wearing sandals or inadequate footwear in winter months 2
• Minimize cold exposure after initial insult to prevent recurrence 2
• Keep extremities consistently warm in cold weather 1

Lifestyle Modifications

• Smoking cessation is essential, as smoking exacerbates vasospasm 1
• Address thin body habitus if present, as low BMI (<25th percentile) increases susceptibility 2

Pharmacological Treatment Options

First-Line Medication

• Nifedipine (calcium channel blocker) is the most evaluated treatment and has demonstrated effectiveness in reducing pain, facilitating healing, and preventing new lesions 1, 2
• Nifedipine produces vasodilation, counteracting the vasospasm underlying chilblains 2
• Note: Effectiveness is not confirmed by all studies, but it remains the best-supported option 1

Alternative Pharmacological Options (When Nifedipine Ineffective or Contraindicated)

• Pentoxifylline has shown positive effects in a limited number of patients 1, 4
• Topical nitroglycerin may provide benefit in select cases 1
• Hydrochloroquine can be considered, particularly if underlying lupus is suspected 1

Non-Pharmacological Alternative

• Acupuncture appears to provide benefit in some patients 1

Important Diagnostic Considerations

Rule Out Secondary Causes

Before treating as idiopathic chilblains, screen for underlying conditions: 1, 2, 4

• Systemic lupus erythematosus (particularly chilblain lupus erythematosus) 4
• Antinuclear antibody testing 2
• Cryoproteins and cold agglutinins 4
• Antiphospholipid antibodies in adults 2
• Anorexia nervosa in children 2

Differential Diagnosis

• Distinguish from Raynaud's phenomenon (sharply demarcated pallor/cyanosis of shorter duration—hours rather than days) 2
• Exclude frostbite (actual tissue freezing with necrosis) 2
• Consider skin biopsy in dubious cases (shows dermal edema, inflammatory infiltrate particularly around eccrine glands) 1

Clinical Pitfalls to Avoid

• Do not apply sudden heat to cold-exposed extremities—this worsens vasospasm 3
• Do not dismiss as purely cosmetic; chilblains cause intense pain, itching, or burning 2
• Do not overlook that lesions typically develop 12-24 hours after cold exposure 2
• Remember that chronic pernio occurs with repeated cold exposure and requires more aggressive prevention 2

Prognosis and Follow-Up

• Acute pernio is usually self-limited and resolves spontaneously, typically disappearing in spring or early summer 1, 2
• Prognosis for properly treated pernio is excellent 2
• Recurrent disease is common without adequate preventive measures 2
• Peak presentation occurs during December to February in cold climates 3