Chilblains

 

Chilblains are itchy and/or tender red-purple, acral, nodules that occur as a reaction to cold.  They are caused by the vasoconstriction of the deep cutaneous arterioles along with concomitant dilatation of the smaller, superficial vessels.  Most cases are primary (idiopathic), however, some cases are secondary to an underlying condition.  Contributory factors include familial tendency, peripheral vascular disease, low body weight e.g. anorexia nervosa, and hormonal changes.  Causes of secondary perniosis include connective tissue disorders (particularly chilblain lupus erythematosus, or systemic sclerosis associated with Raynaud's phenomenon), haematological malignancy, cryoglobulinaemia, and antiphospholipid syndrome

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Diagnosis

NOTE:  Chilblains are diagnosed on clinical grounds

Suspect chilblains in people with one or more intensely itchy, painful, swollen skin lesions that appear within 12–24 hours of exposure to cold

  • The lesions appear as single or multiple (usually symmetric) red patches, papules, or plaques on a cool, oedematous base. They are usually accompanied by intense itching, burning, or pain
  • They are found on exposed extremities, most commonly the toes and fingers. The face (nose, cheeks, and the ear lobes) and legs (heels, shins, thighs, and hips) can also be affected
  • The colour can change from red to purple (or marked darkening in people with dark skin), and swelling can progress to painful, deep purple indurations. In severe cases, it can lead to blistering or ulceration

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Arterial circulation is normal on physical examination

NOTE:  Investigations for chilblains are generally not indicated but should be considered if the history or examination raise the possibility of a systemic cause (such as systemic lupus erythematosus) or if the person's history does not indicate excessive cold exposure (for example consider a full blood count to exclude haematological disorders). Consider seeking specialist advice if in doubt

Click here for differential diagnosis

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Self-care advice

  1. Explain that chilblains are caused by exposure to cold and can be prevented
    1. Although they are uncomfortable, chilblains do not cause permanent damage and will heal on their own if further exposure to cold is avoided
    2. Chilblains are likely to recur in cold weather; this can be minimized with self-care measures
  2. Recommend the following measures to minimize exposure to the cold:
    1. Protect the fingers and hands by wearing gloves
    2. Protect the head and ears by wearing a hat and scarf
    3. Wear appropriate socks and shoes to insulate the feet from the cold
    4. Wear adequate clothing to keep the body warm. Clothing should be loose and in layers to trap body heat
    5. Keep dry to reduce heat loss
  3. Advise the following to reduce the risk of complications:
    1. Do not scratch or rub chilblains
    2. Do not directly overheat chilblains (for example using hot water)
  4. Inform the person that no evidence supports the use of over-the-counter topical preparations for chilblains, and they are not recommended
    1. These products might be considered by patients as they are widely available to buy over-the-counter (for example, Balmosa®, Deep Heat®, and Mentholatum Vapour Rub®)
  5. Encourage smoking cessation

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Treatment and Prescribing

Drug treatment should not be routinely prescribed for the treatment and prevention of chilblains

  • If it is prescribed, drug treatment should only be used in addition to self-care measures

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In adults, only consider prescribing drug treatment:

  • To treat a severe episode of chronic chilblains
  • To prevent recurrent episodes of severe chilblains despite appropriate self-care measures

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Seek specialist advice before prescribing drug treatment for:

  • Children younger than 18 years of age
  • Women who are pregnant or breastfeeding
  • Adults for whom nifedipine is not suitable or is not tolerated

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If drugs are indicated for the treatment or prophylaxis of severe chilblains:

  • Initiate therapy with modified-release nifedipine 20 mg daily
  • If this is not tolerated, consider initiating treatment at a lower dose using immediate-release nifedipine 5 mg capsules

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Continue treatment until the lesions have healed, or for the rest of the cold season if prophylaxis is indicated

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Click here for images

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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