Thursday, November 29, 2007

Winter's Toes

Abstract: 18 yo boy with pruritic, erythematous toes.

History: The patient was referred by his pediatrician with complaints of red, itchy lesions on his toes for two to three weeks. The pediatrician was concerned because some of the lesions looked vasculitic. The patient is in good general health. A non-smoker. He recollected as the interview progressed that he'd had similar but less severe problems in the past.

Physical Exam: Erythematous macules, some hemorrhagic in appearance on toes. One lesion slightly necrotic.
Photos:


Lab: CBC, ANA and other tests ordered at pediatric office
Pathology: none

Diagnosis: Chilblains (Lupus Pernio)
Reasons Presented and Questions: Similar patients are seen two or three times a year in my office. The typical case is a child or young adult with pruritic erythematous macules or papules on the toes or fingers. The lesions can look necrotic and sometimes ulcerate. The person is otherwise healthy. Pernio is most commonly seen in fall or winter, but I've seen it in spring, too. The lesions are worrisome in appearance to physician, parent, patient. The index case here was worried that "my toes will rot off." His mother was worried about "lupus." I reassured them that this is a common, self-limited problem. While nifedipine may help, it's not necessary. Wear warm socks. Give it time. There's a good review on emedicine.com. It says: "The direct cause of pernio is cold exposure. Chronic pernio may be secondary to various systemic diseases as follows:
Chronic myelomonocytic leukemia
Anorexia nervosa
Dysproteinemias
Macroglobulinemia
Cryoglobulinemia, cryofibrinogenemia, cold agglutinins
Antiphospholipid antibody syndrome
Raynaud disease"

But it's usually easy to differentiate which ones are worrisome and the vast majority will be simple chilblains. One may need to use some clinical judgment. Not rush to unnecessary testing. In my experience, and from what I've read, this occurs more when it is cold and damp in thin individuals. Not bone chilling cold, but the cold of early winter. When it is really cold, good socks and footwear may be more the norm and can protect a susceptible individual from chilblains.

11/29/07 -- Patient just seen:
These are the toes of a 70 yo man who has had chilblains for the past 30 winters. His toes are uncomfortable, itchy and occasionally painful. He's had no chronic illnesses and enjoys good health.


Here is an excellent full text reference: "Pernio in Children" from the journal, Pediatrics.

5 comments:

  1. Khalifa SharquieDecember 01, 2007

    Regarding perniosis was a common problem in Iraq in winter time mainly ds of young females as they wear sandles in winter???and wash with cold water.The rash is cold and itchy on heat exposure especially at night and this exacerbates the condition as they can not tolerate heat exposure.It can simulate erythema multiforme or erythema nodosum but here the rash is hot and non itchy.It can effect both hands feet together or each one seperately.Fortunately is decreasing for the last few years as winter is no more cold as usual but still I see many cases each winter. K. Sharquie, Baghdad, Iraq

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  2. Anwar FarfanDecember 01, 2007

    My experience is nothing in comparison to your knowledge. In this cases I agree with you. It is chilblains. But we should exclude any underlining systemic disease such as DM. It may be a kind of teania pedis. with my great appreciation. Anwar Farfan, Yemen

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  3. Once the damage is done there is little you can do to reverse it. The main thing is advice to stop it happening again, namely adequate footwear, avoid damp and cold, maintain core body temperature, do not walk barefoot on cold surfaces etc. In severe cases, at unexpected times of the year, I look for cryoproteins.
    Ian McColl.Gold Coast Australia.

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  4. I agree with Ian that it is dificult to reverse the process once the damage is done or once the process has started. So, it is advisable not to let it begin by avoiding dampness and cold before the winter sets in. Prophylactic nifedipine is more effective than the therapeutic nifedipine in my experience. Intractable cases with severe pain sometimes require a tapering course of oral corticosteroids. Antibiotics are sometimes needed to treat the superaded infection in advanced cases. Topical steroids do not seem to work. I have experienced some success with topical heparin cream or gel instead.

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  5. It's an important part of the foot but we must know how to fix the problems. Bandaging an injured finger or toe accomplishes two things. First, it protects the injury and promotes healing. Second, it stabilized the injured appendage

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