Nifedipine Dosing for Perniosis
For perniosis (chilblains), nifedipine should be dosed at 20-60 mg daily, typically starting at 20 mg and titrating up to 60 mg daily as needed for symptom control, though the evidence for its efficacy is conflicting and it should not be considered first-line therapy.
Evidence Quality and Recommendations
The evidence for nifedipine in perniosis is limited and contradictory:
Dosing Regimen Based on Available Studies
- Start with 20 mg daily of nifedipine (extended-release formulation preferred) and titrate up to a maximum of 60 mg daily in divided doses based on response 1
- The original positive trial used doses ranging from 20-60 mg daily, with most patients responding within the therapeutic window 1
- Treatment duration should be at least 6 weeks to assess efficacy, as lesion clearance may take several weeks 1
Critical Evidence Limitations
The most recent and highest quality study contradicts earlier findings:
- A 2016 randomized controlled trial found nifedipine 60 mg daily (30 mg twice daily) was NOT superior to placebo for chronic chilblains, showing a nonsignificant difference of only 1.84 mm on visual analogue scale (P = 0.44) 2
- This directly contradicts the 1989 trial that showed benefit at 20-60 mg daily 1
- The 2016 study was methodologically rigorous, double-blind, and specifically designed to replicate the earlier positive trial 2
Alternative Considerations
Given the conflicting evidence for oral nifedipine, consider:
- Topical nitroglycerine 0.2% ointment showed promising results with 18 of 22 patients achieving complete regression within 2 weeks 3
- Topical therapy avoids systemic side effects while providing local vasodilation 3
- Calcium channel blockers may actually worsen erythromelalgia (a related condition), and discontinuation has led to symptom resolution in some patients, suggesting caution with this drug class for microvascular disorders 4
Practical Approach
If you choose to trial nifedipine despite mixed evidence:
- Use extended-release formulation starting at 20 mg once daily 5, 1
- Titrate by 20 mg increments every 1-2 weeks up to maximum 60 mg daily 1
- Monitor for hypotension, peripheral edema, dizziness, and flushing which are common side effects 5, 2
- The 2016 trial showed significantly higher incidence of edema with nifedipine compared to placebo 2
- Assess response after 6 weeks of therapy at maximum tolerated dose 1, 2
- If no improvement after 6 weeks at 60 mg daily, discontinue as further benefit is unlikely 2
Important Caveats
- Avoid immediate-release nifedipine due to risk of precipitous blood pressure drops that could paradoxically worsen digital perfusion 6
- The maximum FDA-approved dose for extended-release nifedipine is 180 mg daily for other indications, but doses above 60 mg have not been studied for perniosis 5
- Primary management should focus on cold avoidance, protective clothing (gloves, warm socks), and keeping extremities warm and dry 7