As the winter season rolls in, so do the annoying, itchy, painful wheals known as chilblains. Affecting millions worldwide, these lesions tend to develop in winter when the cold and humidity levels drop rapidly. Chilblains, also called pernio, describe a localized inflammatory response to cold that is often difficult to manage. As the majority of those affected ignore them as minor seasonal irritations, they are in fact complex conditions that require proper diagnosis and treatment plans. Abnormal reactions of small blood vessels in the skin cause this condition in response to cold temperatures, resulting in the inflammation, swelling and characteristic red or purple marks on affected parts. For those who live in frozen climates or are outdoors frequently, understanding chilblains is essential for proper management. This article covers all you need to know about chilblains from diagnosis to prevention and management strategies.
Early Chilblains Symptoms and Affected Areas
Chilblains are caused when skin gets cold and moist, then suddenly warms up again. This process causes significant vasodilation of skin blood vessels that rapidly expand, damaging the fragile hair-like vessels that bring blood to the surface of the skin. Blood leaks into tissue surrounding the vessels and causes swelling and inflammation with characteristic symptoms. With this condition, you will notice red or purple patches on the skin of toes, fingers, heels, nose and earlobes. The skin swells and becomes stiff and painful with mild to intense itching. An electric burning sensation often occurs, causing discomfort that worsens as the affected skin heats up. The skin may become tight and uncomfortable, making it difficult to fit shoes and gloves without pain.
Warning Signs of Early Onset
Once the chilblain is forming, the pruritus and swelling can be very uncomfortable; however the initial tingling, numbness or feelings of coldness through the affected toes, fingers, genitals, etc may be the first clearest indication of a problem. Especially in those who experience Raynaud’s syndrome, early on signs include mild skin redness, slight temperature differences and numbness or prickling sensation. At this early stage the affected skin is only slightly irritated without overt signs of inflammation. Other signs include increased sensitivity or hypersensitivity to touch of the already affected skin areas. As the process develops, the red patches become pronounced and raised, developing into blisters and ultimately open weeping wounds, leading to secondary bacterial infections if untreated. The incubation period is estimated at 1-2 weeks after the initial injury.
Progression and Duration
Chilblains develop most quickly in the first week after cold stress. The extreme itching is normal in the two days to a week that follow, peaking when the unwanted warmth returns after exposure. All symptoms normally resolve completely within 2-4 weeks unless the individual is reexposed to the offending environments. With repeated cold stress without preventative mitigation, the ‘victim’ may develop cryotherapy for the duration of winter season.
Common Causes of Chilblains Development
There are many factors leading to chilblains; however the common denominator is caused in response to poor circulation. Those with existing circulation issues are more prone, as the blood vessels are already sluggish and less capable of making appropriate responses. This provides a plausible explanation for the predominantly distal locations – e.g. the fingers and toes – affected by the vascular reduction. Particular groups demonstrate greater incidences of chilblains than the rest of the population. Females are disproportionately affected over males, as are those in a state of undernutrition or decreased fat/protein stores. Those of old or young age (and therefore inferior blood supply) also impact the statistical picture.
Environmental Causes
Cold conditions are the prime trigger, especially when combined with high humidity. Malignant or injured environments are more conducive with the actions of freezing temperatures and inadequate protection leading to hypothermanent issues. Sudden changes in temperature – for example going from a cold car to a warm house – directly contribute to chilblain severity. Lifestyle factors such as smoking are linked with them, because the constriction of blood vessels and restriction of blood flow increases the likelihood of vascular damage occurring. Similarly various medications that constrict blood flow, or affect blood vessel dilatation, result in increased occurrences of chilblains. Such drugs include beta blockers or statins as a few examples. Certain allergenic or autoimmune conditions such as HIV will worsen circulation, leading to more frequent and severe symptoms. And definitely don’t discount any genetic links….and certainly do not overlook other medical factors such as blue toe syndrome and Raynaud’s phenomenon when understanding the reasoning behind poor circulation issues.
Chilblains Prevention and Treatment Strategies
Prevention strategies are based on the simple utilization of effective warmth throughout the self. Using numerous light garments in layers is more effective against chilblains than one heavy layer that traps pockets of heat. Merino wool and manmade materials in the internal layer aid wicking away excess moisture but still retain warmth without losing heat to damp or moisture. The outer most layer should be water resistant. Feet and hands should be kept dry at all times, and quality waterproof shoes worn at all times outside. Your feet need to breathe but must be adequately protected with a layer of insulation – so consider picking shoes that are wider and larger than normal, so you can wear thicker socks without cramping the toe-box. It does no good to sweat profusely and then get cold, so avoid anything that causes you to reach that unpleasant experience. Moisturizing or barrier creams applied regularly during the day help avoid cracking of already inflamed skin.
When the lesions appear, start by gently warming any high risk areas like the toes and fingers by keeping them in lukewarm water (no hotter than ~21°C) for about 15 minutes. Repeat as often as needed until the symptoms are relieved. Do not use gas or electric driers, as these worsen tissue damage, or static heat sources such as radiators, fireplace, or central heating. Once warmed up, keep fingers and toes in warm socks and mittens. Fotwear should be water proof with a high insulation factor and loose fitting. To ensure the parasites stay dormant, keep the extremities dry but not hot, and put on moisturizer directly afterwards. Use of topical cortisone specific for a mild steroid gives good reduction of the inflammation, but avoid those with alcohol-based ingredients or cortisone creams if blistering has begun. Apply a high potency OTC antihistamine cream or a premium dose corticosteroid cream to minimize itching sensation by glancing at the affected fingers or toes. If any blister forms, splint it as close to the skin as possible, and use a petroleum-based antibiotic ointment or paste on any open areas to deter bacterial infection. Use pain relievers as needed but stay away from aspirin or acetaminophen. Continue to apply topical steroids locally to decrease the itching sensation if required. Avoid the bitch, the chronic itching will give great pause and consider if an OTC writer for the time being will help enhance your ability to go on with daily functioning.
Most importantly, maintain warm conditions with special attention given to extremities until the chilblains heal. Do not scratch the lesions as they will cause further inflammation. Keep affected extremities clean and dry as much as possible. Do not scratch the lesions as you can increase inflammation. Keep the affected areas dry and covered as much as possible. Do not excessively heat hot or cold packs as the conditions can be worsened. Keep fingernails short to help control the desire to scratch often and apply caustic topical agents if one prefers not to scratch. Keep a close watch on the affected fingers and toes and continue with the soakings and use of topical anti-inflammatory preparations as long as possible. If inflammation persists, even with appropriate conservative measures, prompt intervention with appropriate NSAID’s and Corti costs should ensue at once to control inflammation. Encourage re-warming of the hands and feet through necessary wandering outside in addition to the use of indirect heat sources including radiators.
Treatments that may be beneficial include the use of NSAIDs such as indomethacin, NSAID such as aspirin. Vasodilatation to restore blood flow to the marant and low doses of corticosteroids may be necessary if inflammation does not regress. Consider retrograde masses of the respective and use for best results include corticosteroids, histamine agonists and calcium channel blocker administration to regulate inflammation, control pruritus and alleviate the ulcers present.2
Analysis of remaining cases of the identified condition can lead to better prevention and ongoing management of this disorder and assist in identifying the causative etiologic agents so these can be avoided wherever possible.3 Amongst suggested clinical interventions to optimize outcome and improve management it is recommended patient education, use of archiving strategies and monitoring of living conditions and environment for optimal qualitative understanding to eventually eradicate the condition for all patients.4 (See references below).
Furthermore, upon chilblain development, the various treatment options stated are generally effective, and resolution of lesions will usually be accomplished within 2-4 weeks without further intervention needed. Should resolution be unsatisfactory, and/or the lesions become progressive or continue to regress.. modern medical interventions may be utilized including corticosteroids, prostaglandins and other vasodilatory herbal agents.5
These effects are best obtained through the use of epoprostenol, a potent vasodilators to effect systemic blood flow rates and improve overall circulation. The use of oral, or injectable, contraindicate application results in markedly increased systems and is associated with release in the fish. Regular use has shown efficacy in the long term management of chilblains as it controls sympathetic vasospins received in the patient.5 Taking care of the toes, in response to chilblains, is crucial to preventing and minimizing symptoms to the barest minimum. Avoid friction to limit tissue shearing, and use well-fitting shoes and socks that do not constrict especially at the seams to prevent even more trauma.
Apply soaks and topical antiinflammatory agents as noted previously until the symptoms subside completely, then maintain similar practices to prevent further episodes. Progression of this condition without proper management can lead to exacerbations that extend the duration of lesions and include localized tissue necrosis that can develop into gangrene leading to autoamputation of the damage digits. It is well within the healthcare practitioner’s scope of practice to treat individuals with chilblains with the aforementioned therapies and continue monitoring the condition through outpatient follow up until complete resolution is obtained.6
The end point in every case should be patient satisfaction of disease clear skin and no major residual sequelae. At this stage, the patient should be left with a sense of reassurance as to the chronic management of chilblains, and be able to cope well with ongoing episodes. With diligent application of the above principles, the pain and itching of chilblains can be minimized and individuals can continue on with daily life comfortably.