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Chilblains--a pernicious affliction.

A simple condition affecting limb extremities can be dismissed by health professionals as a minor disorder of scant concern. The discomfort and disability caused by chilblains however during winter months can create misery in the afflicted and can cause foot problems in diabetics. Non-sufferers often consider the affliction to be a trifling malady and the subject for ribaldry.

Chilblains are common, usually benign, inflammatory lesions of the skin resulting from an abnormal reaction to a moderate degree of environmental cold. The initial development of erythema pernio can alarm and puzzle patient and health professional, although the skin manifestations of chilblains are readily recognisable. Chilblains commonly affect about 10% of the population at some stage of living.

Chilblains can occur at any age, but are more common in children and elderly people. The condition also affects women more than men. Certain people, such as those with poor circulation, are more susceptible to the condition. Chilblains are common in the UK as damp, cold weather prevails in winter. Some people develop chilblains which last for several months every winter. The wider provision of domestic and industrial central heating has reduced their prevalence but a new group of sufferers has appeared with the advent of potent drugs used for serious health conditions. Patients being treated with beta blockers for arterio-vascular and cardiac conditions often develop chilblains as a drug side effect. The medication can impair the peripheral circulation.

They are more common in young, thin women under the age of 30. The dictates of fashion in this age group, may be incriminated in causation, with skimpy foot and leg wear resulting in unprotected exposure of lower legs and feet to winter damp and cold,. Scantily-clad young women who resort to weekend pub-crawls in inclement cold winter weather conditions often appear a few days later displaying the unattractive, characteristic, discoloured itchy lesions. They are an environmental hazard for people who live in cold, dank climates in autumn and winter which disappears with improvement in ambient temperatures and humidity. Environmental dampness is a contributory factor for in extremely cold countries chilblains are rare, but frost bite is a concern.

Primary causation remains unclear but there is a genetic factor. Chilblains are the result of an abnormal reaction to the cold. When the skin is cold, blood vessels near the surface get narrower. If the skin is then exposed to heat, the blood vessels become wider, if this happens too quickly, blood can leak into the surrounding tissue. This is thought to be the reason for the swelling and itchiness associated with chilblains. They often occur in people who complain of persistently cold hands and feet who may have an insufficiency of capillary circulation in the extremities. Occupational exposure to prolonged standing can result in toes being affected. Chilblains are more common where general health is impaired. Usually, there is no history of localised trauma at the chilblain site and skin injury does not appear to be a causative agent.

The lesions are usually bilateral and symmetrical, but may be single or multiple in presentation. They tend to affect skin parts which can cool profoundly such the hands and feet, with thumbs rarely affected. Areas involved become intensely itchy and red and often are associated with a burning sensation. The redness becomes replaced by deeper reddish or purple colour with pruritus turning to soreness and pain Tender blue nodules can persist for 10-14 days. Most are self-limiting unless reexposure to cold recurs. The swelling can increase with occasional blistering and slow healing. In severe cases swelling can bring vesicles, bullae, petechial bleeding and ulcers. Chilblains can occasionally become confluent, with feet becoming swollen. Repeated scratching can excoriate the skin and bring concomitant infection especially in the older patient with poorer immunity and thin, aged skin.

Differential diagnosis should consider other possibilities.

Cold injury and localised hypothermia can cause several skin conditions some of which may be confused with chilblains and should be considered in making a diagnosis. In mild frost-bite there may be signs of necrotic damage and other areas of the body may be affected.

Chapping occurs where there is cooling of the skin and water loss from the tissues causing the skin to disintegrate rather than flex. Badly chapped skin can show erythema, oedema, Assuring, bleeding and crusting.

Acrocyanosis is a persistent dusky red discoloration of hands and feet due to venostasis and peripheral deoxygenation. The condition can be seen in people with paraplegia due to muscle weakness and skin temperature change.

Eryhrocyanosis is often seen on the backs of legs of young women habitually with bare legs or wearing thin stockings and tights. It gives a persistent bluish discoloration of the leg skin.

Localised vasculitis where there is inflammation round a small blood vessel may be mistaken for a developing chilblain.

A developing paronychia has to be considered, but usually there is evidence of infection and pus around the nail to differentiate the condition and rarely herpetic whitlow can mimic paronychia and add to confusion.

Rarely they may be associated with the serious condition systemic lupus erthematosis

Despite these considerations, the diagnosis is usually straight forward and management can be defined. Special attention should be given to diabetic patient sufferers.

Chilblain risk increases in people,

* with poor peripheral circulation

* age over 50

* living in cold conditions

* living in humid conditions

* where other medical conditions are present e.g. Anaemia,.

Complications of chilblains

--Infection from blistered or scratched skin.

--Ulcers.

--Permanent discolouration of skin.

--Scarring.

Management

Many treatments have been tried and found wanting. Folk remedies have included mustard baths and Vitamin C ingestion. The value of a treatment is difficult to assess as any apparently efficacious remedy has to be weighed against the beneficial variable of warm climatic change occurring during treatment. Some past treatment favourites can prove harmful, such as Vitamins D which can have a detrimental effect on renal function if taken overtime.

The patient should be advised to keep legs and feet warm, use loose woollen socks and leggings and avoiding those of nylon manufacture. Other clothing should be light and porous. Vigorous daily exercising is recommended ideally taken indoors. Use of an exercise bike can be advantageous. Residence in warm housing and a heated work environment is beneficial. The use of heat sources such as hot water bottles, or warming of limbs in close proximity to a strong fire should also be avoided to prevent skin injury and potential infection. Fortunately the advent of domiciliary Central heating has greatly reduced the incidence of "Tinker's Tartan" the blotchy, discolorations of shins and front of the feet once a common sight in elderly women who crouched over open hearth fires to keep warm.

The value of topical applications to feet and legs remains in dispute. If the chilblain hasn't broken the surface, the skin can be painted with a mixture of friar's balsam and a weak solution of iodine. Pruritis and soreness may be alleviated by use of topical antihistamines and antiseptics. Foot balms and emollient creams may be soothing. Those containing menthol and menthol salicylate are in common use. Topical circulatory preparations containing methyl nicotinate have their devotees. Topical applications have to be used with care as several over the counter preparations interact in people taking coumarin anticoagulants. Topical and fluorinated corticosteroids should not be used as they delay the healing process in the lesion.

Gps will often prescribe oral vaso-dilators such as calcium channel-blockers which significantly reduce the time before lesions clear. Diltiazem opens up blood vessels to allow increased blood flow around the body and nifedipine increases the amount of blood that reaches the extremities. They are often prescribed for high blood pressure or angina but are potent medications not free of hazardous side effects and flushing and headache are common occurrences in those taking this medication. They do prevent the development of new chilblains.

The diagnosis and management of a simple condition can present management problems if there is little evidence based research supporting specific treatments. The podiatrist should be aware of drugs in clinical use which can cause chilblains and possible interactions with medications when topical applications are used. The role of the therapist is to ensure that their further development is discouraged and that treatment does no harm. Simple topical applications can be soothing, the advent of Spring will see the disappearance of the unwanted irritating lesions. The resistant have to may be referred to the gp. for a short course of a vasodilator if deemed appropriate.

Patient advice

=> Reduce risk by limiting exposure to the cold.

=> wear warm clothes and ensure home is well heated.

=> keep physically active avoid cigarette smoking.

=> avoid tight fitting shoes and boots.

=> If skin gets cold, warm it up gradually.

=> Avoid heating the skin too quickly, for example by placing feet in ho water or near a heater.

References

McIntosh I Footcare for the elderly-the gps role Geriatric Med. Feb 1992 55-8

Charlton R Chilblains--a guide to diagnosis and treatment Prescriber June 2001 18-23,

Hedrich CM (1), Fiebig B, Hauck FH, Sallmann S, Hahn G, Pfeiffer C, Heubner G, Lee-Kirsch MA, Gahr M. Chilblain lupus erythematosus--a review of literature. Clin Rheumatol. 2008 Aug; 27(8):949-54. doi: 10.1007/ S10067-008-0942-9. Epub 2008 Jun 10.

Cappel JA1, Wetter DA (2). Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011. Mayo Clin Proc. 2014 Feb; 89(2):207-15..

Mireku KA, Glover MH, Davis L. Tender macules and papules on the toes. JAMA Dermatol. 2014 Mar; 150(3):329-30. doi: 10.1001/jamadermatol. 2013.6717. Pramanik Tl, Jha AK, Ghimire A. A retrospective study of cases presenting with chilblains (Perniosis)in Out Patient Department Of Dermatology, Nepal Med
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Title Annotation:TECHNICAL ARTICLE
Author:McIntosh, Iain B.
Publication:Podiatry Review
Article Type:Disease/Disorder overview
Date:Jan 1, 2015
Words:1624
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