Erythema Pernio, (Chiblains)

Question 1

What is the definition of erythema pernio

Answer 1

A vasospastic disorder resulting in localised ischemia due to an abnormal response of the blood vessels to very cold environments.

Question 2

Signs and symptoms of chilblains

Answer 2

lesions appear 12-24hrs after exposure
*burning and itching sensation
*Erythematous and swollen lesions and bullae/ulceration in severe cases
*located in extremities
*acute may manifest for 1-3 weeks
*chronic persists eve after cold season has ended

Question 3

Name some differential diagnoses

Answer 3

Raynauds
Trench foot
Covid toes

Question 4

Aetiology of chilblains,
Name some environmental factors and host factors

Answer 4

Primary idiopathic pernio -
*ENVIRONMENTAL factors
-exposure to damp cold conditions
-rapid change in temperature
-poor insulation - inadequate hoisery, thin soled shoes, chill damp working conditions
(other contributory factors
-familial tendency, low body weight, hormonal changes)

Secondary Aeitiology (HOST)
*Defective Thermoregulation
-auto-immune diseases
-hypothyroidism
-Peripheral vascular disease

Question 5

What does auto-immune mean

Answer 5

Where your immune system attacks healthy cells and tissue in the body resulting in inflammation and damaged tissue

Question 6

which 3 other autoimmune disease can cause localised inflammation and damage which restrict blood flow?

Answer 6

SLE systemic lupus erythematosus
Polyarthritis
Raynauds

Question 7

what is chilblain Lupus Erythamatosus (CLE)

Answer 7

It is associated with systemic lupus erythematosus
Persistent violaceous plaques, prominent over dorsal IPJ of digits
Usually accompanied by other cutaneous features such as discoid(disc-like) lupus erythematosus

Question 8

Hypothyroidism is a condition which can cause defective thermoregulation. Briefly explain what it is

Answer 8

Endocrine disorder, an underactive thyroid.
The thyroid gland does not produce enough thyroid hormone
Inability to tolerate cold-can increase risk of chilblains

Question 9

Peripheral vascular disease is another condition that can affect thermoregulation.
briefly explain what it is

Answer 9

PVD is inadequate blood supply to the extremities
reduced oxygen reaching the tissues - anaemia
Ageing- atherosclerosis, immobility (chilling of superficial tissues)

Question 10

Name the 4 stages of Chilblains

Answer 10

vasoconstriction (cyanotic)
Hypereamic
Congestive
Ulcerative

Question 11

Pathology of chilblains (Erythema Pernio, perniosis,)

Answer 11

Exposure to cold –vasoconstriction and dilation of shunt vessels occurs. results in the build-up of metabolites in the interstitial fluid. Digits appear pale, cold, and cyanotic due to the build-up of toxins and lack of oxygenated blood.

(Rewarming)
Hyperaemic phase
Extreme vasodilation as a result of prolonged abnormal vasoconstriction (vasospasm) causing tissue hypoxia and build-up of metabolites. vascular flow is elevated due to decrease in resistance during cyanotic (constrictive phase). Digits appear bright red, inflamed and patients may complain of a burning sensation.

Congestive phase
Drainage of the venules is not adequate due to the
excessive inflammation present. The affected digits
appear red/purple due the build-up of waste products and
begin to itch, Irritation, erythema, localised oedema, red/purple.

Ulcerative phase
Not all patients will progress to this stage. The chilblain
can breakdown and become ulcerated dependant on the
susceptibility of the patient and external factors including,
poor tissue viability, location etc. The ulceration maybe
self-inflicted due to the itching experienced and can take
weeks to heal particularly if a secondary infection occurs

Question 12

At which stage do digits appear white

Answer 12

Vasoconstriction

Question 13

At which stage do digits appear bright red

Answer 13

hypereamic

Question 14

At which stage do digits appear purple

Answer 14

Congestive (accumulation of waste products)

Question 15

Treatments- what are the objectives

Answer 15

1) prevent tissues becoming excessively cold
2) incorporate thermal insulation into management plan.
3) Footwear & hoisery appraisal and advice

Question 16

In the hyperaemic stage what medicaments can we offer?

Answer 16

Hyperaemic stage - Cooling agents/astringents
-witch hazel
-industrial methylated spirits
-cold compress
-calamine

*reduces blood flow through superficial arterioles and capillaries reduce flow from the capillaries and therefore oedema and pain
* reduce metabolic rate

Question 17

which medicaments would we suggest in the Congestion phase?

Answer 17

Rubefacients - Iodine solution/ointment and
mild analgesic action
-menthol and methyl aslicylate

*produce a mild local inflammation when applied to the skin.
*Causes redness (rubar)
results in vasodilation arising in the removal of metabolites. It also increases the uptake of o2 in the blood in the capillaries and tissues
*counter-irritant - produces superficial inflammation to reduce deeper inflammation
*excess can lead to blistering
*stimulates healing
* reduce pain.

Question 18

What medicament would we offer to reduce itching

Answer 18

Anti-puritic - calamine lotion (rubefacient) or witch hazel (cools).

Question 19

ulcerative phase, what happens in this stage

Answer 19

Tissue necrosis - delayed return of blood flow
break in the epidermal barrier, entry of bacteria increasing the risk of infection

or

Patient induced
- irritation causing scratching of the lesions
-trauma from tight ill fitting footwear

Question 20

What are some advice you would give a patient

Answer 20

Do not go out in very cold weather
wear gloves and socks and keep skin dry
Rewarm the skin slowly by rubbing or massaging
Do not place on direct heat
Apply lotion to alleviate itching
wear woolly socks and thicker-soled shoes.