Chilblains

Chilblains, also known as pernio and chill burns,[2] are a medical condition in which damage occurs to capillary beds in the skin, most often in the hands or feet, when blood perfuses into the nearby tissue resulting in redness, itching, inflammation, and possibly blisters.[3] It occurs most frequently when predisposed individuals, predominantly women, [4] are exposed to cold and humidity. Ulcerated chilblains are referred to as kibes. Temperature-related chilblains can be prevented by keeping the feet and hands warm in cold weather and avoiding exposing these areas to extreme temperature changes. Once the diagnosis of chilblains is made, first-line treatment includes avoiding cold, damp environments and wearing gloves and warm socks.[5]

Chilblain
Other namesPernio, chill burn, perniones, perniosis[1]
Toes inflamed by chilblains
Pronunciation
  • /ˈtʃɪlbleɪnz/
SpecialtyEmergency medicine

Chilblains can be idiopathic (spontaneous and unrelated to another disease), but similar symptoms may also be a manifestation of another serious medical condition that must be investigated. Related medical conditions include Raynaud's disease, erythromelalgia, frostbite, and trench foot, as well as connective tissue diseases such as lupus or vasculitis. In infants affected by Aicardi–Goutières syndrome (a rare inherited condition which affects the nervous system) chilblain-like symptoms occur together with severe neurologic disturbances and unexplained fevers.

Chilblain-like symptoms have also been linked to COVID-19.[6][7][8] COVID toes, as they are commonly known,[9][10] have mostly been reported in older children and adolescents,[11] who often have not had other symptoms of COVID-19.[12] The symptoms are usually mild and disappear without treatment.[11] Their cause is debated: it is uncertain whether COVID toes are a delayed consequence of the viral infection itself (or at least partially connected to environmental factors during the COVID-19 pandemic).[9][10][13] The occurrence of such lesions has been attributed to the similar interferon-1 mediated immune response in both COVID-19 and systemic lupus erythematosus, another possible explanation is based on a common genetic background.[14] In a recent genome-wide association study, the 3p21.31 region was found to be associated with COVID-19 severity.[15] This region also contains the TREX1 gene. Missense mutations of the TREX1 gene are responsible for familial chilblain lupus and its genetic polymorphisms have been implicated in the pathogenesis of systemic lupus erythematosus. The TREX1 mutation significantly reduces its exonucleolytic activity which results in the accumulation of nucleic acids that can stimulate type-I interferon responses and trigger autoimmunity. Thus an alteration in TREX1 activity, perhaps due to a promoter/enhancer modulation, may be responsible for the coincidence of both viral infection and an autoimmune phenomenon such as chilblain.[16] They may share some of the microscopic features of chilblains caused by lupus.[12] It has been suggested that in the absence of exposure to cold and damp, COVID-19 should be considered as a possible cause of chilblains.[12]

Signs and symptoms
Chilblains from excessively icing the feet

The areas most affected are the toes, fingers, earlobes, nose.

Chilblains caused by exposure to low temperatures usually heal within 7–14 days.

Prevention

Exposure
  • Keep affected area warm, and avoid any extreme temperature changes (including very hot water).[17][18]
  • Keep affected area dry.[19]
  • Wear warm shoes, socks and gloves.[18]
  • Wear a hat and a scarf to protect the ears and the nose.[18]
  • Avoid tight fitting socks/shoes.

Other
  • Exercise at least four times a week to improve circulation.[18]
  • Quit smoking, as it damages circulation.[17]

Treatment

Treatment for the condition depends on its cause. Below are some common treatments for chilblains caused by exposure to low temperatures, though some may also apply to other sources of the condition.

  • A course of vitamin B, especially nicotinic acid, may improve circulation.
  • Soaking in warm water with Epsom salts for 15–20 minutes, 3–4 times a day.
  • A topical steroid cream may relieve itching.
  • Nifedipine, a vasodilator, may help in some cases.[20] Vasodilation may reduce pain, facilitate healing, and prevent recurrences.[21] It is typically available in an oral pill but can be compounded into a topical formula.
  • Diltiazem, a vasodilator, may help.[22]
  • Apply a mixture of friar's balsam and a weak iodine solution.[18]
  • Avoid restricting the affected area.[23]

History

The medieval Bald's Leechbook recommended treating chilblains with a mix of eggs, wine, and fennel root,[24] and a modern home remedy is to put garlic on the chilblains.[25] Neither of these remedies has been supported by scientific research.

See also

References
  1. James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 978-0-7216-2921-6.
  2. SJ; et al. SJ'.
  3. Cold Stress: Chilblains. National Institute for Occupational Safety and Health. Retrieved January 6, 2009.
  4. Beuscher T.L., Andrews S.E. What Are COVID Toes? A Case Study. J. Wound Ostomy Continence Nurs.. 2020;47(6):619-621. doi:10.1097/WON.0000000000000711
  5. Beuscher T.L. & Andrews S.E. (2020). What Are COVID Toes? A Case Study. Journal of Wound, Ostomy and Continence Nursing, 47, 619-621. https://doi.org/10.1097/WON.0000000000000711
  6. Wollina U, Karadağ AS, Rowland-Payne C, Chiriac A, Lotti T (2020). "Cutaneous signs in COVID-19 Patients: a review". Dermatologic Therapy: e13549. doi:10.1111/dth.13549. PMC 7273098. PMID 32390279.
  7. Young S, Fernandez AP (2020). "Skin manifestations of COVID-19". Cleveland Clinic Journal of Medicine. doi:10.3949/ccjm.87a.ccc031. PMID 32409442.
  8. Kaya G, Kaya A, Saurat JH (June 2020). "Clinical and histopathological features and potential pathological mechanisms of skin lesions in COVID-19: review of the literature". Dermatopathology. 7 (1): 3–16. doi:10.3390/dermatopathology7010002. PMID 32608380. In acral chilblain-like lesions, a diffuse dense lymphoid infiltrate of the superficial and deep dermis, as well as hypodermis, with a prevalent perivascular pattern and signs of endothelial activation, are observed.
  9. Massey PR, Jones KM (May 2020). "Going viral: A brief history of chilblain-like skin lesions ("COVID toes") amidst the COVID-19 pandemic". Seminars in Oncology. doi:10.1053/j.seminoncol.2020.05.012. PMID 32736881.
  10. Bristow IR, Borthwick AM (June 2020). "The mystery of the COVID toes – turning evidence-based medicine on its head". Journal of Foot and Ankle Research. 13 (1): 38. doi:10.1186/s13047-020-00408-w. PMC 7309429. PMID 32576291.
  11. Walker DM, Tolentino VR (June 2020). "COVID-19: The impact on pediatric emergency care". Pediatric Emergency Medicine Practice. 17 (Suppl 6-1): 1–27. PMID 32496723.
  12. Ladha MA, Luca N, Constantinescu C, Naert K, Ramien ML (August 2020). "Approach to chilblains during the COVID-19 pandemic". Journal of Cutaneous Medicine and Surgery: 1203475420937978. doi:10.1177/1203475420937978. PMID 32741218.
  13. Unusual coronavirus (COVID-19) symptoms: What are they?
  14. Jabalameli, Navid. "Overlap between Genetic Susceptibility to COVID-19 and Skin Diseases". Immunological Investigations. doi:10.1080/08820139.2021.1876086. PMID 33494631.
  15. Ellinghaus. "Genomewide Association Study of Severe Covid-19 with Respiratory Failure". doi:10.1056/NEJMoa2020283. PMID 32558485. Cite journal requires |journal= (help)
  16. Jabalameli. "Overlap between Genetic Susceptibility to COVID-19 and Skin Diseases". Immunological Investigations. doi:10.1080/08820139.2021.1876086. PMID 33494631.
  17. Harvard.edu. https://www.health.harvard.edu/newsletter_article/what-can-i-do-about-chilblains. Retrieved 31 May 2020. Missing or empty |title= (help)
  18. "What are chilblains (pernio)? What causes chilblains?". Medical News Today.
  19. "Chilblains.org – #1 Online Source for Treatments, Prevention, Relief Advice". Chilblains.org.
  20. Rustin, M.H.A.; Newton, Julia A.; Smith, N.P.; Dowd, Pauline M. (2006). "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". British Journal of Dermatology. 120 (2): 267–75. doi:10.1111/j.1365-2133.1989.tb07792.x. PMID 2647123.
  21. Simon, T. D.; Soep, JB; Hollister, JR (2005). "Pernio in Pediatrics". Pediatrics. 116 (3): e472–5. doi:10.1542/peds.2004-2681. PMID 16140694.
  22. Patra, AK; Das, AL; Ramadasan, P (2003). "Diltiazem vs. nifedipine in chilblains: A clinical trial". Indian Journal of Dermatology, Venereology and Leprology. 69 (3): 209–11. PMID 17642888.
  23. "Chilblains.com.au – Information, Treatment and Prevention". Archived from the original on 2016-03-05. Retrieved 2019-11-06.
  24. Robert Lacey and Danny Danziger August: The Year 1000: What Life Was Like at the Turn of the First Millennium Little, Brown, 2000 ISBN 0316511579
  25. "Remedios caseros para sabañones". saludplena.com (in Spanish). Retrieved 29 December 2016.
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