What is the appropriate treatment for chillblains (pernio)?

Treatment for Chilblains (Pernio)

For chilblains, the primary treatment is prevention through cold avoidance and keeping extremities warm, with nifedipine as the most evidence-based pharmacologic option for symptomatic relief and prevention of new lesions. 1, 2

Immediate Management and Prevention

• Remove the patient from cold exposure immediately and rewarm the affected limb by cleaning, drying, and allowing gradual rewarming 1
• Prevention is the most effective therapy: minimize cold exposure after initial presentation, wear appropriate protective clothing (avoid sandals in winter), and keep extremities consistently warm 1, 3
• Smoking cessation is essential as it exacerbates vasospasm 2

Pharmacologic Treatment

First-Line Medication

• Nifedipine (calcium channel blocker) is the most studied and effective treatment for reducing pain, facilitating healing, and preventing new chilblain lesions through vasodilation 1, 2
• Nifedipine's effectiveness has been demonstrated in clinical practice, though some studies show variable results 2

Alternative Pharmacologic Options

• Topical betamethasone is commonly used but lacks confirmation from randomized controlled trials 2
• Pentoxifylline, hydroxychloroquine, and topical nitroglycerin have shown benefit only in limited patient populations 2
• Botulinum toxin injections may be considered for severe, refractory ulcerative cases, particularly in chilblain lupus erythematosus 4

Clinical Evaluation Required

Before initiating treatment, exclude secondary causes through targeted evaluation:

• Screen for underlying autoimmune disease, particularly systemic lupus erythematosus and antiphospholipid antibodies in adults 1, 3
• Check for cryoproteins, monoclonal gammopathy, cryoglobulinemia, or chronic myelomonocytic leukemia 3
• Obtain antinuclear antibody profile to exclude connective tissue disease 1, 3
• Consider skin biopsy in dubious cases (shows dermal edema and inflammatory infiltrate, particularly around eccrine glands) 2

Natural History and Prognosis

• Acute chilblains are usually self-limited, developing 12-24 hours after cold exposure and typically resolving spontaneously over 2-3 weeks 1, 3
• Lesions characteristically begin in fall/winter and disappear in spring/early summer 1
• The prognosis for properly treated chilblains is excellent, though recurrence is common with repeated cold exposure 1

High-Risk Populations

Certain patient characteristics increase susceptibility:

• Thin body habitus (BMI <25th percentile) is associated with increased cutaneous vasoreactivity 1
• Young women are most commonly affected, though children and older individuals can develop chilblains 1
• Elderly patients, females, outdoor workers, and those with chronic/recurrent episodes are less tolerant to cold 5
• Ambient temperature <10°C combined with relative humidity >60% significantly increases risk 5

Critical Differential Diagnoses

Distinguish chilblains from:

• Raynaud's phenomenon: sharply demarcated pallor/cyanosis followed by erythema, lasting hours rather than days 1
• Frostbite: actual tissue freezing with resultant necrosis (requires rewarming at 37-40°C per established protocols) 6
• Vasculitis or cutaneous leukemia: excluded through thorough history, physical examination, and laboratory evaluation 3

Common Pitfalls to Avoid

• Do not confuse chilblains with frostbite—chilblains occur with non-freezing cold exposure, while frostbite involves actual tissue freezing 6, 1
• Do not overlook underlying systemic disease, particularly in adults or those with atypical presentations 3
• Recognize that chilblains can occur even in warmer climates during winter months, and providers in these regions may be unfamiliar with the presentation 3