What is the best treatment approach for a 28-year-old female patient with chilblains?

Treatment of Chilblains

For a 28-year-old female patient with chilblains, the primary treatment is prevention through cold avoidance and extremity warming, with oral nifedipine (typically 20 mg three times daily) as the first-line pharmacologic therapy for severe or persistent cases. 1, 2

Initial Management and Prevention

• Immediate cold avoidance and extremity warming are mandatory as the cornerstone of treatment, since chilblains result from an abnormal vasospastic response to cold, non-freezing wet conditions 1, 3
• Counsel the patient to keep extremities warm and dry, wear appropriate protective clothing (avoiding fashion choices like sandals in winter), and minimize cold exposure after initial presentation 1, 4
• Smoking cessation is essential if applicable, as smoking impairs peripheral circulation and exacerbates vasospasm 1

Pharmacologic Treatment for Severe or Persistent Cases

First-Line: Oral Nifedipine

• Nifedipine is the most evidence-based pharmacologic treatment for chilblains, producing vasodilation that reduces pain, facilitates healing, and prevents new lesions 3, 2
• A systematic review of 576 patients found moderate evidence supporting nifedipine for severe or refractory idiopathic chilblains 2
• Typical dosing is 20 mg three times daily, though effectiveness varies among studies 1

Alternative Pharmacologic Options

• Pentoxifylline has moderate evidence as an alternative for severe or refractory cases based on systematic review 2
• Topical corticosteroids (such as betamethasone or clobetasol propionate) are commonly used but lack confirmation from randomized controlled trials 1, 4
• Other treatments with limited evidence include topical nitroglycerin, hydrochloroquine, and diltiazem, showing benefit only in small patient numbers 1, 2

Clinical Presentation to Confirm

• Look for painful, pruritic, red-to-purple papular or edematous lesions on acral surfaces (fingers, toes) developing 12-24 hours after cold exposure 1, 3, 5
• Symptoms include intense burning, itching, or pain that distinguishes chilblains from Raynaud's phenomenon (which has sharply demarcated pallor/cyanosis lasting hours, not days) 3
• Young women with low BMI (<25th percentile) are the highest-risk population 3, 4, 5

Essential Workup to Exclude Secondary Causes

• Screen for systemic symptoms and underlying autoimmune disease, particularly systemic lupus erythematosus and antiphospholipid antibodies in adults 1, 3
• Obtain antinuclear antibody profile and consider cryoprotein testing to exclude secondary causes 3
• Evaluate for anorexia nervosa in thin patients, as this predisposes to chilblains 3
• Skin biopsy is reserved for dubious cases, showing dermal edema and inflammatory infiltrate particularly around eccrine glands 1

Expected Course and Follow-Up

• Acute chilblains are usually self-limited, resolving spontaneously with proper rewarming and cold avoidance 1, 3
• Lesions typically begin in fall/winter and disappear in spring/early summer 3
• Chronic chilblains occur with repeated cold exposure, requiring more aggressive prevention strategies 3
• The prognosis for properly treated chilblains is excellent, though recurrence is common without adequate prevention 3, 4

Critical Pitfalls to Avoid

• Do not perform extensive vasculitis or thromboembolic workup based solely on appearance, as this leads to unnecessary testing and delays in care 5
• Do not confuse with frostbite (which involves tissue freezing and necrosis) or Raynaud's phenomenon (shorter duration with sharply demarcated color changes) 3
• Do not rely solely on topical corticosteroids as definitive treatment for severe cases, as their efficacy is unproven despite common use 1
• Do not overlook underlying conditions in adults, particularly lupus and antiphospholipid syndrome 1, 3