Pernio (chilblains)

SARS-CoV-2 Vaccination and Chilblain-like Lesions: What Do We Know so Far?

INTRODUCTION

The coronavirus pandemic has caused massive damage to global health care and the economy. The vaccination program has been paced around the globe to return as soon as possible to pre-COVID time. Although all the vaccines have been approved after the rigorous clinical and safety trials, some adverse effects have surfaced and are being reported from different parts of the world. One such side effect is chilblain-like lesions following the COVID vaccination. Chilblain lesions, also known as pernio, are an inflammatory condition usually affecting the acral regions of the body. It is mostly reported from cold and damp areas and has multiple causes associated with it.

OBJECTIVE

This study aims to review the publicly available data and to provide concise and comprehensive information as well as evaluate the potential pathology, clinical approach, and management of CLL post-vaccination.

METHODS

An extensive literature search over PubMed, Cochrane library, Google Scholar, and Clinicaltrails. gov from inception till 5th October 2021, without any restriction of language was carried out. All the recruited articles were reviewed, and their bibliographies were also screened for any relevant information.

RESULTS

12 studies (10 case reports and 2 case series) were retrieved reporting the incidence of CLL post-vaccination. 8 studies reported incidence in female patients while 5 reported in males, with one study mentioning no gender. Moreover, most of them were either from Europe or the United States of America, except for two cases, reported from Turkey.

CONCLUSIONS

Although the overall incidence of Chilblains following COVID-19 vaccination is low, there is still a strong need to find out the exact mechanism behind this to redefine the safety and administration criteria of the vaccines and to formulate a proper management protocol.

New use of old medicine: Nifedipine acts on the TRP family and inflammatory proteins in the treatment of chilblain

As a calcium antagonist, the mechanism of nifedipine for treating chilblain has not been reported. In the present study, we established the chilblain model by using -20 ℃ 95% ethanol to freeze the right back foot of SD rats, and investigated the effects of this drug. Hematoxylin-eosin (HE) examination indicated most of pannus in the skin tissue of chilblain rats had disappeared, and the local inflammatory cells were also greatly reduced when given nifedipine at 15.0 mg/kg/d. The enzyme-linked immunosorbent assay (ELISA) revealed that nifedipine inhibited release of inflammatory factors TNF-α, IL-6, IL-1β and VEGF in serum. The RT-PCR analysis showed that nifedipine down regulated mRNA levels of TRPC-6 and VEGF in skin tissue. Furthermore, immunohistochemical examination showed nifedipine inhibited expression of IL-1β, IL-6, and TNF-α inflammatory protein and further inhibited expression of TRP (transient receptor potential) family proteins TRPM-7, TRPC-1, TRPC-3 and TRPC-6 and reduced expression of VEGF in skin and relieved erythema and oedema. This study demonstrated that nifedipine as an old medicine can be new use for the treatment of chilblain by acting on TRPs family and inflammatory proteins.

Raynaud's phenomenon and related vasospastic disorders

Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.

Chilblains

Idiopathic chilblain is a relatively common yet poorly recognized acrosyndrome. This literature review aims to better understand and draw attention to this disorder. Chilblain is a localized inflammation of the skin that occurs on exposure to cold but non-freezing wet weather. It usually resolves spontaneously. The etiology is uncertain, but vasospasm seems to play a role in this abnormal reaction to cold. Diagnosis is most often based on clinical presentation, but a skin biopsy can be useful in dubious cases. In histology, dermal edema and an inflammatory infiltrate are usually present. A distribution of the infiltrate particularly around the eccrine gland is typical. Systemic symptoms and underlying autoimmune disease should be screened. Avoiding cold and keeping extremities warm is the first recommendation for management, as well as smoking cessation. Calcium channel blockers (in particular nifedipine) seems to be the treatment that has been most evaluated in chilblains. However, their effectiveness is not confirmed by all studies. Topical betamethasone is often used but its effect has not been confirmed by randomized clinical trials. Other treatments, such as pentoxifylline, hydrochloroquine and topical nitroglycerin have shown positive effects only in a reduced number of patients. Acupuncture seems to bring a benefit.

Phenotypic familial aggregation in chronic chilblains

BACKGROUND

Our clinical observations and two earlier studies indicate familial clustering to be involved in chronic chilblains. Demonstrating phenotypic familial aggregation is a next step to investigate the origin of familial clustering.

OBJECTIVE

This study was initiated to assess evidence for phenotypic familial aggregation in chronic chilblains.

METHODS

Using a case-control family design in a primary care setting, we computed the familial relative risk of at least one episode of chronic chilblains during life with 95% confidence intervals (CIs). The study population consisted of 192 relatives of 31 case probands (at least one confirmed episode of chronic chilblains). The control population consisted of 178 relatives of 31 sex- and age-matched index controls (no history of chronic chilblains).

RESULTS

The familial relative risk of chronic chilblains was 3.6 (95% CI 1.9-7.3). Additional sensitivity analysis shows similar figures.

CONCLUSION

We demonstrate robust phenotypic familial aggregation in chronic chilblains.

Nifedipine vs Placebo for Treatment of Chronic Chilblains: A Randomized Controlled Trial

PURPOSE

Nifedipine is commonly prescribed for the treatment of chilblains (pernio, perniosis) on the basis of observational studies and a single small, older clinical trial. We aimed to confirm the proposed superiority of oral nifedipine 60 mg per day over placebo for treatment of chronic chilblains in primary care.

METHODS

We performed a randomized, placebo-controlled, double-blind, crossover trial, closely following the design of the older trial. A total of 32 patients with chronic chilblains were randomly assigned to nifedipine (30 mg controlled release twice a day) or placebo. The primary outcome was patient-reported complaints; the secondary outcome was patient-reported disability. Both were assessed from daily ratings on 100-mm visual analogue scales recorded in a diary. We took ambient temperatures into account and checked for a carry-over effect, and monitored for adverse effects.

RESULTS

After 6 weeks of treatment, mean scores on the visual analogue scale on complaints showed a nonsignificant difference of 1.84 mm (95% CI, -6.67 to 2.99 mm) in favor of nifedipine (P = .44). Mean scores on the visual analogue scale on disability showed a nonsignificant difference of 0.56 mm (95% CI, -2.97 to 4.09 mm) in favor of placebo (P = .75). There was no carry-over effect of prior study treatment. Nifedipine was associated with significantly lower systolic blood pressure and a significantly higher incidence of edema.

CONCLUSIONS

In our study, nifedipine was not superior to placebo for treating chronic chilblains. These findings contrast with those of the older study and do not support routine use of nifedipine for this condition.

Dermatologic Concerns of the Lower Extremity in the Pediatric Patient

As the largest organ in the body, skin can prove the most daunting to diagnose and manage due to the large number of conditions and their uncanny ability to have similar qualities visually. Skin can reflect current trauma or infections or can be a harbinger of an underlying systemic disorder. With knowledge of the most common pediatric skin conditions, it is possible for practitioners to start a child on a basic treatment regimen and then refer to an appropriate specialist for more complex or rare disorders. This article covers the most common skin conditions seen on the lower extremity in the pediatric population.

Clinical Approach to Diffuse Blisters

Some blistering eruptions are self-limited, but others are life threatening, and prompt diagnosis and management are critical. The clinical presentation of vesicles and bullae suggests a broad differential and this article (1) highlights some common diagnoses that may be encountered by primary care physicians and subspecialists; (2) provides a possible systematic diagnostic approach to such patients, including history, physical examination, and relevant work-up.

Chilblain lupus erythematosus

Chilblain lupus erythematosus is a rare form of chronic cutaneous lupus erythematosus. It is characterised by purple plaques/nodules and oedematous skin mainly around the acral regions of the body, which are most exposed to the cold. In this paper we report a case of chilblain lupus erythematosus that was diagnosed using the Mayo Clinic Diagnostic Criteria and its successful treatment with hydroxychloroquine.

Perniosis in an infant treated with topical nitroglycerine

Treatment of perniosis with topical nitroglycerin ointment is reported in a 6-month-old boy.

The capillaroscopic findings in idiopathic pernio: is it a microvascular disease?

OBJECTIVES

Pernio is a disorder that affects the unprotected skin regions of individuals who are exposed to nonfreezing, damp cold. We aimed to examine nailfold capillaries by video capillaroscopy and evaluate the vascular involvement in patients with idiopathic pernio.

METHODS

Fifty-three patients with idiopathic pernio (male/female ratio 35:18, mean age 25 ± 9 years) and 38 age- and sex-matched healthy volunteers (male/female ratio 30:8, mean age 24 ± 4 years) were included in the study. Forty-seven of the 53 patients and all the healthy volunteers were evaluated by nailfold video capillaroscopy.

RESULTS

In the patient group, the mean capillary diameter and the mean apical capillary diameter were 56 ± 15 and 24 ± 7 μm, respectively. In the control group, the mean capillary diameter and the mean apical capillary diameter were 37 ± 8 and 15 ± 4 μm, respectively (both p < 0.001). Both of these differences were independent of the disease activity, smoking, and the number of pernio episodes. There were no architectural derangements, avascular areas, or hemorrhages.

CONCLUSIONS

In the present study, increased nailfold capillary diameter and increased apical capillary diameter were found in patients with pernio regardless of the disease activity. These findings suggest organic damage of the microcirculation.

Perniosis in a long-distance cyclist crossing Mongolia

We report a case of severe perniosis in a long-distance cyclist. This case demonstrates the importance of identifying those at risk of cold-related injuries who are about to embark on extensive travel in cold environments.

Idiopathic chilblains

BACKGROUND

Chilblains is a benign condition infrequently encountered in clinical practice; its resemblance to vasculitis or peripheral thromboemboli can often result in an extensive and unnecessary diagnostic work-up.

METHOD

Three cases of chilblains seen by our Rheumatology service, along with 113 documented cases, were reviewed.

RESULTS

Chilblains is characterized by painful red-to-purple papular lesions involving the acral surface of fingers or toes that resolves with symptomatic treatment. Female sex and low body mass index are risk factors.

CONCLUSION

Distinct clinical features of chilblains can be used for early recognition and management, thus avoiding unnecessary diagnostic testing and delays in patient care.

Health problems in cold work

Cold in- and outdoor work can result in different adverse effects on human health. Health problems decrease performance and work productivity and increase the occurrence of accidents and injuries. Serious health problems can also result in absence from work due to sick leave or hospitalization. At its worst, work in cold conditions could be associated with deaths due to cold-related accidents or a sudden health event. Musculoskeletal complaints, like pain, aches etc. are common in indoor cold work. Breathing cold air while working may lead to respiratory symptoms, which can decrease performance in cold. The symptoms are usually worsened by exercise and ageing, being more common in persons having a respiratory disease. Cardiovascular complaints and related performance decrements could be especially pronounced during work in cold weather and involving physical exercise, especially among those with an underlying cardiovascular disease. The article also reviews the current information related to diabetes, skin disorders and diseases, as well as cold injuries and accidents occurring in cold work. Increasing awareness and identifying workplace- and individual-related cold risks is the first step in proper cold risk management. Following this, the susceptible population groups need customized advice on proper prevention and protection in cold work.

Perniosis (chilblains) masquerading as CA-MRSA: a case report

Perniosis (chilblains) is a vasospastic, inflammatory disease that occurs when the skin is subjected to cold above the freezing point, under damp conditions. Erythematous (violaceous) blisters, ulcerations or pustules that sit on an edematous base, accompanied by pain, burning or itching, are usually evident. To the inexperienced clinician it may resemble community-associated methicillin-resistant Staphylococcus aureus and could lead to inappropriate treatment. Here we report such a case.