What is chillblains and how to manage it in a patient, potentially with underlying conditions like Raynaud's disease?

What Are Chilblains?

Chilblains (also called pernio) are localized inflammatory skin lesions that develop as an abnormal response to cold exposure, appearing as painful, red-purple, swollen areas typically on your fingers or toes. 1

Understanding the Condition

Chilblains develop when your skin is exposed to cold (but not freezing) temperatures, usually appearing 12-24 hours after cold exposure. 1 The lesions are:

• Red-purple, swollen patches on fingers or toes 1
• Painful, itchy, or burning in sensation 1
• Different from frostbite (which involves actual tissue freezing) 1
• Different from Raynaud's phenomenon (which causes sharply demarcated color changes lasting hours, not days) 1, 2

The condition typically starts in fall or winter and resolves in spring or early summer. 1

Who Gets Chilblains?

You may be more susceptible if you have:

• Thin body habitus (lower BMI) 1, 3
• Female gender (more common in young women and adolescent girls) 1, 3
• Underlying conditions like lupus, antiphospholipid antibodies, or inflammatory arthritis 1, 4
• History of cold exposure combined with inadequate protection 1

Important Warning Signs

Seek immediate evaluation if you have chilblains with any of these features, as they may indicate secondary causes requiring different treatment:

• Severe, persistent pain with digital ulcers 5
• Joint pain, skin changes, or systemic symptoms 6
• Fever (rare in simple chilblains) 7
• Tissue necrosis or gangrene 8

These red flags suggest possible underlying conditions like systemic sclerosis, lupus, or vasculitis rather than simple chilblains. 5, 6

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How to Manage Chilblains

Immediate Care

The most important initial step is rewarming and protecting the affected area:

• Clean and dry the affected limb 1
• Rewarm gradually (avoid rapid rewarming) 1
• Avoid scratching or trauma to the lesions 1

Prevention (Most Important)

Prevention is the best therapy—minimizing cold exposure after an initial episode is critical: 1

• Wear proper warm clothing including mittens (not gloves), insulated footwear, and warm socks 5, 6
• Avoid cold and damp conditions 4
• Keep extremities warm and dry at all times 1
• Avoid fashion choices that expose skin (like sandals in winter) 1

Medical Treatment

For Simple (Primary) Chilblains:

Nifedipine is the most effective medication, producing vasodilation that reduces pain, facilitates healing, and prevents new lesions. 1 This is a calcium channel blocker typically used at standard doses. 5

When to Consider Underlying Disease:

If chilblains are severe, recurrent, or associated with systemic symptoms, testing may be needed to exclude:

• Autoimmune diseases (lupus, systemic sclerosis) 1, 2
• Cryoproteins or clotting abnormalities 1
• Antiphospholipid antibodies 1, 4

Laboratory evaluation should include ANA, ESR/CRP, and potentially antiphospholipid antibodies if secondary causes are suspected. 2

For Secondary Chilblains (Associated with Underlying Disease):

Immunosuppressive treatment with corticosteroids and disease-modifying drugs may be necessary if chilblains are associated with inflammatory arthritis or autoimmune conditions. 4 This requires specialist rheumatology evaluation. 4

Expected Course

With proper treatment and cold avoidance, the prognosis is excellent. 1 Acute chilblains are usually self-limited but may recur with repeated cold exposure. 1 Chronic chilblains occur when lesions persist due to repeated cold exposure. 1, 3

Common Pitfalls to Avoid

• Don't confuse chilblains with Raynaud's phenomenon—Raynaud's has sharply demarcated color changes lasting hours, while chilblains persist for days 1, 2
• Don't ignore systemic symptoms—fever, joint pain, or severe ulceration warrant evaluation for underlying disease 6, 7
• Don't allow continued cold exposure—this is the most common reason for treatment failure 1
• Don't use beta-blockers if prescribed for other conditions, as they can worsen symptoms 5, 2