Chilblains
Exam Tips
- Timing is high yield: chilblains usually appear 12-24 hours after non-freezing cold exposure, unlike cold urticaria (minutes) and frostbite (true freezing injury).
- Think secondary cause if lesions are severe, ulcerative/necrotic, unusually persistent, or occur without clear cold trigger; screen for lupus and haematological disease.
- Differentiate from Raynaud: Raynaud gives episodic colour change (white-blue-red), whereas chilblains are persistent inflammatory papules/plaques after exposure.
- In OSCEs, include pulse and sensory examination to exclude peripheral vascular disease and diabetic neuropathy.
- See clinical image examples in dermatology atlases/textbook perniosis chapters (for example acral violaceous papules and plaques in Rook's dermatology perniosis figures) to improve visual recognition.
Definition
Chilblains (perniosis) are localized inflammatory skin lesions triggered by non-freezing cold exposure, most often affecting acral sites such as fingers, toes, ears, and nose. They typically present 12-24 hours after cold/damp exposure as itchy or painful red-purple papules, plaques, or nodules, and may be primary (idiopathic) or secondary to systemic disease (for example lupus or haematological disorders).
Pathophysiology
The core mechanism is an abnormal neurovascular response to cold: prolonged vasoconstriction in deeper cutaneous arterioles with relative dilation and leakage in superficial vessels during rewarming. This causes localized hypoxaemia, oedema, and a lymphocytic inflammatory reaction in the dermis, producing tender/pruritic violaceous lesions. In secondary chilblains, immune-mediated vascular injury (for example connective tissue disease), hyperviscosity/cryoprotein-related occlusion (for example cryoglobulinaemia), or other vasculopathic processes can drive more persistent, ulcerative, or necrotic disease.
Risk Factors
- Cold, damp environmental exposure (autumn/winter), including outdoor work
- Smoking
- Female sex
- Low body weight, malnutrition, or anorexia nervosa
- Peripheral vascular disease
- Family history of chilblains
- Repeated cold exposure (risk of chronic perniosis)
- Underlying connective tissue disease (especially lupus erythematosus)
- Underlying haematological disease (including cryoglobulinaemia, antiphospholipid syndrome, malignancy)
Clinical Features
Symptoms
- Itch (pruritus), burning discomfort, or tenderness in affected areas
- Symptoms often become more noticeable on rewarming after cold exposure
- May be asymptomatic in some patients
- Recurrent seasonal episodes in winter; persistence suggests chronic/secondary disease
Signs
- Symmetrical red-purple macules, papules, nodules, or plaques on acral skin (fingers/toes most common)
- Possible involvement of nose, cheeks, earlobes, heels, lower legs, thighs, or hips
- Blistering or ulceration in severe cases
- Post-inflammatory hyperpigmentation, atrophy, or scarring after resolution
- Severe chronic disease: fibrosis, lymphoedema, hyperkeratosis
- Papular perniosis: small crops on finger sides, often with acrocyanosis
- Equestrian perniosis: clustered indurated red-purple plaques/papules on outer thighs or buttocks after riding in cold weather
Investigations
Management
Lifestyle Modifications
- Reassure that idiopathic chilblains are usually self-limiting (often 2-3 weeks) if further cold exposure is avoided
- Gradual rewarming and careful drying of skin; avoid direct heat sources (fire, heater, hot water bottle directly on skin)
- Keep whole body and extremities warm/dry: layered clothing, insulated gloves/socks/footwear, avoid damp socks/shoes
- Smoking cessation advice (nicotine worsens vasoconstriction)
- Reduce recurrent cold exposure at work/leisure where possible
- Skin care to reduce trauma/scratching and secondary infection risk
Pharmacological Treatment
Calcium-channel blocker (vasodilator, off-label for chilblains)
- Nifedipine modified-release 10 mg twice daily initially; may increase to 20 mg twice daily if needed and tolerated
Used for recurrent or severe idiopathic disease despite conservative measures; evidence is mixed. Safety: can cause headache, flushing, dizziness, ankle oedema, and hypotension. Avoid in significant hypotension, cardiogenic shock, or severe aortic stenosis; check interactions (for example strong CYP3A4 inhibitors such as clarithromycin). Counsel about postural symptoms.
Topical corticosteroid (symptom relief)
- Betamethasone valerate 0.1% cream/ointment thinly once or twice daily for short course (for example up to 7-14 days)
May reduce itch/inflammation but does not correct underlying cold vasoreactivity; avoid prolonged continuous use on thin skin to reduce atrophy risk.
Simple analgesia
- Paracetamol 500 mg-1 g every 4-6 hours when required (maximum 4 g/day in adults)
Use for pain control; adjust dose in low body weight or hepatic impairment.
Antibiotics (only if secondary infection develops)
- Flucloxacillin 500 mg four times daily for 5-7 days (adult, if non-purulent cellulitis likely staphylococcal/streptococcal)
Not routine for uncomplicated chilblains. Use local antimicrobial guidance and allergy alternatives (for example macrolide) where indicated.
Complications
- Excoriation from scratching
- Secondary bacterial skin infection
- Blistering and ulceration
- Tissue necrosis in severe cases
- Post-inflammatory pigmentation change
- Scarring and atrophy (especially chronic/recurrent disease)
Prognosis
Idiopathic chilblains generally have an excellent prognosis and settle within days to a few weeks when cold exposure is reduced. Recurrence is common in later cold seasons, and repeated episodes may become chronic over winter. Prognosis is less favourable when lesions are secondary to systemic disease, where outcome depends on control of the underlying condition.
Sources & References
✅NICE Guidelines(1)
- Chilblains[overview]
📖Textbook References(1)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1652)[context]