Chilblains—medically termed pernio or perniosis—are inflammatory lesions that arise on acral skin after exposure to cold, damp, non-freezing air. They are classified as primary (idiopathic) or secondary when associated with systemic disorders such as connective-tissue disease, cryoglobulinaemia or haematological malignancy. The condition has been recognised for over two centuries, yet its pathophysiology remains incompletely understood.
What do chilblains look and feel like?
Symptoms usually begin within 12-24 hours after cold exposure and rewarming. The initial sensation is burning or itching, followed by single or multiple erythematous-violaceous papules or plaques that are oedematous and tender. Over the next few days lesions may enlarge, coalesce or develop vesicles, haemorrhagic bullae and shallow ulcers with serous crusts. Colour changes progress through violaceous brown to post-inflammatory hyperpigmentation that can persist for weeks after resolution. Chronic pernio may produce persistent erythema, scaling and lichenification. Lesions are typically symmetrical and spare the palms and soles.
Why do chilblains develop and who is most at risk?
The essential trigger is a combination of low ambient temperature (typically 0–15 °C) and high humidity that does not reach frostbite levels. Cold exposure induces arteriolar vasoconstriction; during rapid rewarming a reactive hyperaemia occurs, but the efferent limb of the local vascular response is impaired, leading to leakage of plasma and a perivascular infiltrate composed predominantly of T lymphocytes. Epidemiological data show the condition is commonest in young to middle-aged women, especially those with low body-mass index, smokers, outdoor workers and individuals with pre-existing connective-tissue diseases such as lupus erythematosus or dermatomyositis, Raynaud phenomenon, cryoglobulinaemia or peripheral vascular disease.
How is chilblains diagnosed?
Diagnosis is clinical. A history of cold exposure followed by characteristic lesions on acral sites is usually sufficient. Skin biopsy is rarely needed but, when performed, shows dermal oedema, perivascular lymphocytic infiltrates, endothelial swelling and, in chronic cases, fibrin deposition and thrombosis of small vessels. Dermoscopy under low magnification reveals regular dotted vessels on a reddish-violaceous background with peripheral scaling; this pattern can be useful in atypical presentations. Laboratory tests are not required in primary pernio, but may be indicated when secondary causes are suspected: complete blood count, erythrocyte sedimentation rate, antinuclear antibodies, complement levels, cryoglobulins and serum protein electrophoresis can help exclude underlying systemic disorders.
What are the advantages of dermascopy?
IBOOLO Dermoscopy offers several concrete advantages that make it valuable in daily clinical practice. First, it is immediate: the examination takes place at the bedside or in the outpatient room, and magnified images are available within seconds, allowing clinicians to decide on the same visit whether to biopsy, treat or monitor a lesion. Second, it is non-invasive and painless; the instrument simply rests on the skin surface or, when used for mucosal lesions, on the moist epithelium, causing no discomfort and leaving no scar. Third, it is comfortable for both patient and operator: modern handheld devices weigh less than 200 g, require no coupling gel, and can be used in any body site without special preparation. Because of these features, dermoscopy can be repeated as often as needed for digital follow-up, reducing anxiety and the need for unnecessary excisions.
How are chilblains treated?
Management begins with removal of cold exposure. Affected areas should be rewarmed gradually; direct heat or vigorous rubbing is avoided because it may exacerbate inflammation. First-line pharmacological therapy consists of moderate-potency topical corticosteroids (triamcinolone acetonide 0.1 % ointment applied twice daily) to reduce pruritus and oedema. Nifedipine, a peripheral vasodilator, is recommended for recurrent or ulcerated cases at an initial dose of 20 mg daily, titrated to 60 mg daily if tolerated; randomised controlled trials have shown a significant reduction in both lesion count and healing time. Pentoxifylline (400 mg three times daily) and topical minoxidil 5 % solution have been reported to improve cutaneous perfusion and may be considered in refractory patients. Secondary bacterial infection, most frequently with Staphylococcus aureus, is treated with oral flucloxacillin or clarithromycin for 7–10 days. Phototherapy with narrow-band ultraviolet B has been used in small case series for chronic pernio with partial benefit.
How can chilblains be prevented?
Prevention centres on avoidance of cold, damp environments and maintenance of peripheral circulation. Layered clothing should include moisture-wicking inner garments and wind-proof outer shells; socks and gloves should be loose to prevent compression. Smoking cessation is strongly advised because nicotine compounds peripheral vasoconstriction. Regular aerobic exercise improves microcirculation, while adequate caloric intake and correction of iron-deficiency anaemia reduce risk in underweight individuals. After cold exposure, rapid but gentle rewarming—using lukewarm water or warm towels—prevents abrupt vasodilation. Pharmacological prophylaxis is rarely required, but patients with recurrent ulcerated lesions may benefit from winter courses of nifedipine 20 mg daily under medical supervision.