CHILBLAINS: Causes, Symptoms, and Prevention

Chilblains, also known as Pernio, is an inflammatory skin condition triggered by prolonged exposure to cold, damp conditions. It is derived from two old English words, “Chill” and “Blain“. Chill means cold, and blain stands for sore. Although often considered rare, it affects many individuals in colder climates and was first formally described in 1888. This condition commonly affects acral areas of the body (extremities such as toes, fingers, ears, and nose). It is more prevalent in women than men, particularly those aged between 15 and 30. Chilblains are especially common among women in early adulthood and those residing in cold, damp regions such as the UK and parts of Northern Europe. Inadequate protection against cold weather can increase the risk of developing chilblains.

Because of its strong association with cold weather, chilblains cases typically rise during the winter months. They are categorized as either primary or secondary. Primary chilblains occur without an underlying cause and usually resolve on their own within two to three weeks. In contrast, secondary chilblains are associated with systemic conditions, particularly immune-mediated inflammatory diseases (IMIDs), hematological disorders, or malignancies. Without proper care, symptoms may worsen or become chronic.¹Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100

History of Chilblains

Seven cases of chilblains were found in San Francisco from November 1986 to January 1978. Chilblains is a vascular skin condition associated with cold weather, specifically cold but not freezing temperatures in European and Western areas. 
When chilblains develop without a clearly identifiable cause, they are referred to as primary or idiopathic. In the UK, it is estimated that about 1 in 10 people will experience chilblains at some point in their lives. While anyone can be affected, older individuals and those with impaired peripheral circulation are more susceptible.

Symptoms of Chilblains

The symptoms of chilblains mostly appear in the winter because cold weather triggers this disease. Most patients become normal when the weather warms up again. That’s why chilblains are also called seasonal diseases. It mainly affects the toes and changes the color of the toes. Moreover, it also causes swelling or inflammation in the toes.²Padeh, S., Gerstein, M., Greenberger, S., & Berkun, Y. (2013). Chronic chilblains: the clinical presentation and disease course in a large pediatric series. Clinical and experimental rheumatology, 31(3), 463–468.

Initially, patients feel itching on their fingers, toes, and noses, but itching becomes painful after some time. Later, purple patches or plaques also begin showing on the fingers and toes. Other signs of this disease include feeling a burning sensation, peeling the toes, and thickening the skin with tiny red, brown, and purple spots. It mainly targets the toes but can also impact the hands, ears, nose, and face. Swelling on hands and thighs is also a noticeable effect of this disorder.

Symptoms of chilblain may appear suddenly, beginning within 12 to 24 hours after the climate condition changes. Most symptoms disappear within a few weeks, but cold weather triggers this disease, so it may return the following year when the weather becomes cold again.³Dubey, S., Joshi, N., Stevenson, O., Gordon, C., & Reynolds, J. A. (2022). Chilblains in immune-mediated inflammatory diseases: a review. Rheumatology (Oxford, England), 61(12), 4631–4642. https://doi.org/10.1093/rheumatology/keac231

How do we diagnose Chilblains? 

Doctors typically examine the skin of affected patients. In some cases, doctors advise patients to go for a blood test or skin biopsy, but in most cases, a simple examination of the OPD is enough. If the brief examination of the patient’s skin shows symptoms such as redness, swelling, and itchiness on the toes and fingers, then there is a chance that the patient has developed the disease. These few physical tests are usually enough to diagnose chilblains.⁴Maraj, D. C., & Barak-Norris, R. (2021). A Case of Longstanding Idiopathic Pernio/Chilblain Disease. Cureus, 13(9), e17674. https://doi.org/10.7759/cureus.17674

Preventive measures to reduce the risk of Chilblain

Preventative measures are the best treatment that doctors advise for patients affected by chilblains disease. In the beginning, doctors advise patients to avoid exposure to cold weather. However, in some severe cases, it may require medical therapy. The medical treatment includes certain medications, lotions or creams, and warm baths.⁵Akkurt, Z. M., Ucmak, D., Yildiz, K., Yürüker, S. K., & Celik, H. Ö. (2014). Chilblains in Turkey: a case-control study. Anais brasileiros de dermatologia, 89(1), 44–50. https://doi.org/10.1590/abd1806-4841.20142376

Treatment of Chilblain

Nifedipine is the primary medicine that doctors prescribe when complications occur. It is helpful for the treatment of chilblains due to its vasodilatory effects. A dose of nifedipine 20mg to 60 mg daily prevents the development of chilblains. The medication also helps to reduce pain and soreness. Vasodilators help to open blood vessels. Other pharmacologic options include:

• Topical corticosteroids (such as hydrocortisone cream) reduce inflammation and itching.
• Topical nitroglycerin for its localized vasodilatory effects.
• Nicotinamide (a form of vitamin B3), may improve skin integrity and circulation.
• Pentoxifylline, which enhances microcirculatory blood flow.

Additionally, Balsmosa cream has shown anecdotal effectiveness in reducing itching, though it is less widely studied in comparison to corticosteroids or vasodilators.

These treatments are typically used when conservative measures like warming and protective clothing are not sufficient or when lesions are recurrent or severe.⁶Rustin, M. H., Newton, J. A., Smith, N. P., & Dowd, P. M. (1989). The treatment of chilblains with nifedipine: the results of a pilot study, a double-blind placebo-controlled randomized study and a long-term open trial. The British journal of dermatology, 120(2), 267–275. https://doi.org/10.1111/j.1365-2133.1989.tb07792.x

Standard Self-Care Methods to Avoid Chilblain

Since environmental changes have a role in developing this disease, it is essential to understand some preventive measures to avoid it. These preventive measures and methods help to reduce the risk of chilblain development, specifically for the people who develop it in the cold weather each year. These preventive measures include the following key concerns:

• Patients should avoid cold exposure whenever possible. The patient needs to minimize their interaction with freezing weather and need to use regular warm baths for feet.
• Patients should keep them warm using gloves and socks in cold weather.
• Avoid smoking and try to quit, as smoking can narrow your blood vessels. 
• Keep hands and feet always dry and warm. Don’t scratch the affected skin.
• Warm your skin again and again gently and smoothly while avoiding putting your hands and feet in front of direct heat. 
• Use comfortable shoes because when tight, they rub the skin, which can damage and peel off the affected skin.⁷Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100

Can hot water cure Chilblain?

One of the most frequently asked questions is if chilblain can be treated with hot water, and the answer is No. The areas affected with chilblains should not be directly exposed to heat. The patient should not jump directly into the hot shower or use hot water for the foot massage. Moreover, the patient must avoid exposing the area to the heater after using a cold shower. It will not cure the disease. Hot water can worsen the conditions of your toes. Sometimes, these red patches clear up independently after 1 to 3 weeks. However, you must be careful initially to avoid serious consequences. 

Chilblain’s Relation with Covid

Cases of chilblains increase during COVID-19. According to a Northern California Cohort study, this disease was diagnosed in 1319 patients during the COVID-19 pandemic. Another report shows that 780 patients were affected by chilblains during the pandemic, and 463 were females. In a children’s hospital in Madrid, Spain, 49 cases of chilblains were reported during the first year of the pandemic. Most cases of chilblains are reported in the first and third wave of the pandemic.⁸Mohan, V., & Lind, R. (2020). Chilblains in COVID-19 Infection. Cureus, 12(7), e9245. https://doi.org/10.7759/cureus.9245

A strict lockdown period in the first wave and seasonal temperature in the third wave significantly increased the cases of chilblains. The Spanish Government also reported that during the short six-year week, there was a lockdown in the first wave of the pandemic series, and reportedly 22 patients were affected by this disease.⁹Massey, P. R., & Jones, K. M. (2020). Going viral: A brief history of Chilblain-like skin lesions (“COVID toes”) amidst the COVID-19 pandemic. Seminars in oncology, 47(5), 330–334. https://doi.org/10.1053/j.seminoncol.2020.05.012

Difference between Chilblains & Raynaud’s

Chilblains develop when a cold temperature makes the toes and fingers extremely cold, which consequently interrupts blood circulation and results in redness and itching in the affected areas. The cause behind Raynaud’s is also the interruption in the blood circulation of the toes and fingers, which is why people often assume that Chilblains and Raynaud’s are the same disease. Still, there’s a difference between these two diseases. 

While chilblains are caused by an interruption in the blood vessels due to freezing weather, Raynaud’s are caused when blood vessels are rapidly constricted. During chilblains, the toes appear red and start itching, but the skin color turns white, pale, or blue and then red during Raynaud’s development. The toes also experience numbness, pain, and tingling during Raynaud’s, but the chilblain patients may not experience these. People with Raynaud’s may also experience chilblains, but those with chilblains are not necessarily at the risk of developing Raynaud’s.¹⁰Haque, A., & Hughes, M. (2020). Raynaud’s phenomenon. Clinical medicine (London, England), 20(6), 580–587. https://doi.org/10.7861/clinmed.2020-0754

Different Stages of Chilblains

Chilblains are divided into four stages, where the intensity of the disease changes at each stage. 

Stage 1:

During the first stage of chilblains, the disease may go unnoticed primarily due to vasoconstriction. The symptoms are fewer and seem like common issues to most people that are usually associated with the change in weather or the start of winter. 

Stage 2:

After the initial stages, the toes turn red. During this stage, the extremities of the toes and fingers begin to feel pain. The affected areas turn red, and the patients feel burning in the toes. This stage is called the hyperaemic or erythematous stage of chilblains. 

Stage 3:

The third stage is the congestive or cyanotic, where the affected areas swell. The toes may resolve or ulcerate during this stage.

Stage 4:

During this stage, the patient may suffer from broken chilblain because the extremities of toes and fingers or the impacted site has become traumatized. 

In the first stage, patients need to use cool dressing. In the second stage, the patient needs to use specific creams such as vasodilator cream or may use rubefacients. It is best to minimize exposure to cold, use warm foot baths, and gently massage the area.  In the ulcerative stage, the patients are advised to go for wound dressing. In severe cases, it is best to seek professional guidance.¹¹Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100

It is also essential to consider that if you are a diabetic patient and your chilblain is not disappearing after a few weeks, you need to consult a professional doctor. Furthermore, suppose you are suffering from any immunosuppressed disorder or similar disease or infection that is causing poor circulation and consequently impacting your chilblains. In that case, you should seek professional advice. 

Conclusion

Chilblains is a disease that can be prevented by working on self-care and maintaining a hygienic grooming routine. While it is triggered in the winter, it is also important to note that many measures and methods can be highly helpful in regulating the body temperature even in cold weather, which can consequently prevent the chances of developing chilblains. If you have developed chilblains, you do not need to worry; you must follow the hygiene routine and take prescribed medication to treat the disease.

You will also need to avoid scratching or rubbing the affected skin. If you have any other skin condition along with chilblains, you must seek professional advice before consuming any medication or using any cream on the affected skin. With proper treatment and self-care, chilblains can be healed within 1 to 3 weeks.  However, they typically reoccur when your toes are exposed to extreme cold again, which is why self-care after recovery is equally important. Chilblains is not a dangerous disease and has no long-term impact on your skin or overall well-being. They can be reduced by taking preventive measures and treating the prescribed medications. 

Refrences

• 1
  Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100
• 2
  Padeh, S., Gerstein, M., Greenberger, S., & Berkun, Y. (2013). Chronic chilblains: the clinical presentation and disease course in a large pediatric series. Clinical and experimental rheumatology, 31(3), 463–468.
• 3
  Dubey, S., Joshi, N., Stevenson, O., Gordon, C., & Reynolds, J. A. (2022). Chilblains in immune-mediated inflammatory diseases: a review. Rheumatology (Oxford, England), 61(12), 4631–4642. https://doi.org/10.1093/rheumatology/keac231
• 4
  Maraj, D. C., & Barak-Norris, R. (2021). A Case of Longstanding Idiopathic Pernio/Chilblain Disease. Cureus, 13(9), e17674. https://doi.org/10.7759/cureus.17674
• 5
  Akkurt, Z. M., Ucmak, D., Yildiz, K., Yürüker, S. K., & Celik, H. Ö. (2014). Chilblains in Turkey: a case-control study. Anais brasileiros de dermatologia, 89(1), 44–50. https://doi.org/10.1590/abd1806-4841.20142376
• 6
  Rustin, M. H., Newton, J. A., Smith, N. P., & Dowd, P. M. (1989). The treatment of chilblains with nifedipine: the results of a pilot study, a double-blind placebo-controlled randomized study and a long-term open trial. The British journal of dermatology, 120(2), 267–275. https://doi.org/10.1111/j.1365-2133.1989.tb07792.x
• 7
  Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100
• 8
  Mohan, V., & Lind, R. (2020). Chilblains in COVID-19 Infection. Cureus, 12(7), e9245. https://doi.org/10.7759/cureus.9245
• 9
  Massey, P. R., & Jones, K. M. (2020). Going viral: A brief history of Chilblain-like skin lesions (“COVID toes”) amidst the COVID-19 pandemic. Seminars in oncology, 47(5), 330–334. https://doi.org/10.1053/j.seminoncol.2020.05.012
• 10
  Haque, A., & Hughes, M. (2020). Raynaud’s phenomenon. Clinical medicine (London, England), 20(6), 580–587. https://doi.org/10.7861/clinmed.2020-0754
• 11
  Vano-Galvan, S., & Martorell, A. (2012). Chilblains. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(1), 67. https://doi.org/10.1503/cmaj.110100