Derm Dilemma by Claire Gist
MD Candidate , Class of 2025 , University of Arkansas for Medical Sciences , Little Rock , Ark .
A 65-year-old female presents with a three-week history of tender erythematous 5-10mm papules of the lateral aspects of the right index finger and the left fifth finger . Similar painful papules have occurred previously on the digits of the feet and hands in the colder months of previous years , particularly after spending time outdoors . She has experienced no concomitant systemic symptoms , including fever , shortness of breath , or cough . In previous episodes the papules have resolved spontaneously within a few weeks . Topical application of a triple antibiotic / lidocaine preparation has provided some symptomatic relief but has not expedited resolution of the eruption .
Based on the patient history and clinical images , what is the most likely diagnosis and appropriate intervention for this patient ?
A . Chilblains ( pernio ); insulated gloves and footwear , avoidance of dampness , topical corticosteroids or vasodilators may be employed .
B . Raynaud phenomenon ; screen for underlying autoimmune disease and begin a systemic calcium channel blocker .
C . Covid-19 ; obtain SARS Cov-2 PCR assay ; self-quarantine and appropriate level of intervention depending upon presence and magnitude of symptoms .
D . Erythromelalgia ; screen for underlying myeloproliferative disorder and begin aspirin therapy .
E . Sweet ’ s syndrome ; obtain absolute neutrophil count and serum protein electrophoresis and begin systemic corticosteroids .
Answer : A
Chilblains , also known as pernio , manifests as tender , burning , or pruritic erythrocyanotic papules with a strong predilection for the digits that appear after exposure to cold , damp climates . Persons of any age may be affected , but the condition is most frequently seen in young to middle-aged women . Symptoms characteristically begin in early winter and resolve in the spring . Low body mass index may be a predisposing factor . The exact etiopathogenesis is unclear , but it is presumed that cold-induced vasoconstriction and hyperviscosity result in localized hypoxia which in turn results in an inflammatory response .
Chilblains has been reported in association with autoimmune disorders ( particularly lupus erythematosus ), viral hepatitis and paraproteinemias . More recently , chilblain-like lesions have been described in patients of all ages with Covid-19 ( colloquially termed “ Covid toes ”) even in the absence of cold exposure . With respect to the clinical vignette presented above , the recurrent nature of the eruption in previous years ( prior to the appearance of this coronavirus variant ) makes Covid-19 less likely , although screening would be reasonable .
Management includes minimization of unprotected cold exposure as well as gloves and appropriate footwear . Attempting to keep the skin dry is also helpful . Smoking should be discouraged . Pharmacologic interventions include topical therapy ( corticosteroids , minoxidil , nitroglycerin ) and systemic agents ( e . g ., nifedipine ).
38 • The Journal of the Arkansas Medical Society www . ArkMed . org