GPAtlas🧭 When to suspect
Suspect chilblains (perniosis) when an otherwise well patient develops itchy or burning red-to-violaceous patches or swellings on the acral extremities – classically the toes and fingers, but also the heels, ears and nose – appearing several hours (typically 12–24 hours) after exposure to cold, damp conditions. They are an abnormal inflammatory response to non-freezing cold, not a freezing injury, and are common in the UK's damp winters.
The central clinical skill is not the diagnosis itself – which is usually obvious – but deciding whether you are looking at simple idiopathic chilblains (the great majority, self-limiting and managed with warmth) or secondary chilblains, where cold-induced lesions are the visible tip of an underlying disorder such as chilblain lupus or another connective tissue disease. Secondary causes account for fewer than 7% of cases, but missing them is the principal pitfall.
| Feature | Primary (idiopathic) chilblains | Secondary chilblains – raise suspicion |
|---|---|---|
| Timing | Cold, damp weather; settle as the weather warms | Persist into warm weather or occur year-round |
| Course | Self-limiting over 1–3 weeks | Persistent (> 1 month), recurrent, or ulcerating |
| Distribution | Typical acral sites, symmetrical | Atypical sites or unusually widespread |
| Systemic clues | None – patient otherwise well | Raynaud's, photosensitive rash, arthralgia, mouth ulcers, weight loss |
| Underlying cause | None | Chilblain lupus, connective tissue disease, cryoglobulinaemia, rarely leukaemia |
Consider the diagnosis particularly in patients with predisposing factors: low body weight, poor peripheral circulation, smoking, outdoor cold exposure, and a family or personal history of chilblains or Raynaud's.
Source: DermNet
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