Introduction

Chilblains (pronounced chill-blayns) are a cold-induced inflammatory condition. It is a medical disorder where damage has occurred to the capillary (very small vein) beds in the skin, usually due to cold or damp air.¹ This results in redness, itching, inflammation, and possibly blisters, usually on the hands or feet. These symptoms can show up immediately or hours after being exposed to the cold.

Chilblains, also known as pernio, can occur at any age; both children and adults are equally likely to get them, and they are thought to occur when the skin is warmed up too quickly after it has been cold. The symptoms, however, can change depending on age as children and adults have different clinical presentations. The purpose of this article is to compare and contrast the presentation of chilblains in children and adults, with attention to clinical features, associated conditions, diagnosis, and management.

Pathophysiology of Chilblains

The main cause of chilblains is as a result of a natural bodily response to the cold- those tiny blood vessels (capillaries) contract to reduce heat loss by preventing blood from running close to the skin surface. When you begin to get warm again, blood rushes from the veins into the capillaries at a rate faster than the capillaries can process. This causes blood to leak into the tissues, causing them to be inflamed and swollen, resulting in chilblains.

It is important to note that persistent episodes of chilblains can indicate an underlying disease, such as the involvement of connective tissue disorders and autoimmune diseases. Chilblain lupus, antiphospholipid syndrome and Sjögren Syndrome all have links with chilblains.

The appearance of chilblains may differ between children and adults. Children generally have more elastic (stretchy) blood vessels, which results in chilblains being milder and self-resolving. Whereas in adults, ageing reduces the elasticity of blood vessels (arteriosclerosis), as well as diabetes, hypertension and a higher prevalence of autoimmune diseases.  Furthermore, habits such as smoking reduce the elasticity of blood vessels, causing more serious chilblain symptoms which last longer.

Chilblains in Children

Chilblains are more likely to occur in climates which are cold and damp. Extreme cold climates would not usually result in chilblains due to drier air and better protective clothing. It can present more frequently in children who have less body fat/insulation, and in those who do not dress appropriately for the weather.²

Chilblains in children appear as papules, swelling, itching, burning pain and patches which are reddish-purplish in colour. It is usually a mild case and resolves on its own. Common areas for chilblains include:

• Toes
• Fingers
• Ear lobe
• Nose
• Thighs and legs for those who engage in outside sports such as horse riding.

Symptoms can be eased through over-the-counter painkillers such as paracetamol or ibuprofen. Wearing appropriate clothing while being outside can prevent chilblains from occurring. A thick coat, hat and gloves should help when the weather is cold and damp.

Very rarely in paediatric cases, chilblains can be associated with lupus pernio (chilblain lupus). This can have quite a severe impact on the child; it can affect their mobility, attendance at school and during the colder winter months, they can have a dip in quality of life.

Chilblains in Adults

Chilblains in adults present more commonly in middle-aged adults and the elderly, especially women. The symptoms of chilblains in adults are pretty much identical to those in children:

• Similar chilblain locations (toes, fingers, ears), but lesions are often more persistent
• Symptoms: itching, pain, ulceration, and fissuring are more common than in children

However, unlike in children, the blistering is more common in adults, the pain can be more severe, and there can be the presence of ulcers. These symptoms are also more persistent, and the likelihood of them being recurrent is also increased. Chronic cases of chilblains are also more typical among adults. 

There are also more associated features of chilblains amongst adults. There is a higher likelihood that there is an underlying cause resulting in the secondary presentation of chilblains.¹ Connective tissue disorders and autoimmune diseases increase the chances of having chilblains. Diseases such as antiphospholipid syndrome, rheumatoid arthritis and lupus pernio all have chilblains as a known side effect.³ 

The daily habits and lifestyles of adults can also cause repeated chilblains. Habits such as smoking cause arteriosclerosis (stiffening of blood vessels), increasing potential damage to the capillaries and increasing chances of having chilblains.³  Those with type 1 diabetes or those who have developed type 2 diabetes are also at an increased risk. Those with type 2 diabetes should focus on improving their lifestyle and diet to reduce their chilblain risk. 

As an adult, there may be a greater impact on quality of life. Generally, there is a greater risk of chronic ulcers, which can affect daily life due to pain, and the location on the hands and feet would make it difficult to complete tasks. Additionally, there is also the risk of secondary infections.¹ The itch of the chilblains can be difficult to ignore, the scratching allows bacteria naturally existing on the skin to enter the wound and potentially cause an infection requiring medical attention. The ulcers which form are also an infection risk due to easy entry of bacteria into the body. 

Key differences in presentation

Below is a table to highlight the key differences between chilblains in children and adults:

Management Approaches

Management for chilblains in both adults and children can follow the same general approach. Cold and damp weather or environment should be avoided. Warm clothing should be worn- hats, gloves, warm coats and the use of layers. Adults should stop smoking,³ and parents of children with chilblains should also cease smoking, to prevent passive smoking. 

There are also more specific approaches which can be used to minimise the symptoms or recurrence of chilblains:

Children: 

• Conservative management should be used— gentle warming, emollients, reassurance. Do not place hands around hot beverages (for example, tea, etc.) or hot water bottles. This rapid heating can cause chilblains.low warming techniques should be used instead. Hydrocortisone creams are no longer recommended; instead, unscented lotions are best
• Use of painkillers can also be included if the pain is high
• Systemic therapy (in rare cases)

Adults: 

• Pharmacological intervention may be required- calcium channel blockers like nifedipine, or other vasodilators can be used to prevent the dilation of the capillaries.⁵ Medicines to treat any underlying autoimmune diseases should also be used if relevant
• For chilblains not caused by connective tissue disorders or autoimmune diseases, the same approach of warming should be used. Gentle warming through warm clothes and layers, even the use of warm (not hot) water in the affected areas. Pain medication can also be used such as paracetamol or ibuprofen

Generally, the different approaches lie with how support is provided; children often need emotionally supportive care, whereas adults need systemic therapy interventions.

Prognosis and Outcomes

The prognosis of chilblains differs in children and adults, largely due to adults having more severe cases of chilblains. Children having chilblains are usually seasonal- increased occurrence during the winter months, and the cases are usually benign (not severe). The chances of getting chilblains may decrease with age, too. In contrast, adults having more chronic cases, which are recurrent with more severe complications (ulceration & secondary infections),¹ result in a prognosis which is dependent upon whether there is an underlying cause. The condition can usually be managed through the use of medication, but quality of life can be affected. 

Diagnosis and Differential Considerations

Chilblains are frequently diagnosed by looking at the affected skin patches.⁵ Sometimes, blood tests or skin biopsies may be taken to rule out similar-looking diseases. In children, diseases such as vasculitis or other infections can appear as chilblains, and more serious diseases such as chilblain lupus. All of these would be ruled out when ensuring an accurate diagnosis of chilblains. 

Adults have a more complex diagnosis process. The chilblains can simply occur due to damaged capillaries as a result of cold/damp climates, but if they are recurrent and chronic, a wider exploration of causes needs to take place. Connective tissue disorders and immune-related diseases can have chilblains as secondary side effects. These need to be properly explored to enable the correct medical management. In these instances, it is important that a full medical history is given alongside a physical exam and even blood work. 

Summary

Children and adults can both suffer from chilblains, with the symptoms being generally the same across all ages, but adults get the more severe chronic side of the disease. It is very important for adults to get a careful medical inspection to diagnose an underlying systemic disease causing chilblains. There is specific care which can be provided to both children and adults to reduce the side effects of chilblain episodes.