Introduction

Some people get painful, itchy, red or purple blotches on their fingers or toes when the weather gets wet and chilly. We refer to this as chilblains. They are brought on by extended exposure to cool, damp conditions that alter blood flow in tiny vessels rather than frostbite, which occurs in extremely cold temperatures.

In addition to being moderate and disappearing on their own in a few weeks, chilblains can also be severe and result in infections, blisters (a raised area on the skin filled with fluid), and ulcers (open sores). Physicians have long recommended quitting smoking, staying warm, and avoiding abrupt temperature changes for patients with chilblains. However, why is smoking so closely related?

Over the past two decades, several studies and reviews have looked into this. They show that smoking increases the chance of getting chilblains and makes existing cases worse. The reasons are mostly related to how smoking affects blood vessels and skin healing.¹

Chilblains have been documented in medical literature for centuries. In colder regions of Europe, particularly before the adoption of central heating, doctors frequently saw patients with painful, swollen fingers and toes each winter. They were sometimes referred to as "winter sores." Even now, chilblains are more common in rural locations, colder climates, and wet environments.¹

What are Chilblains? 

Chilblains, or pernio, are inflammatory skin alterations (changes). They look like:¹

• Patches or lumps on the nose, fingers, ears, or toes that are red, blue, or purple
• Itchy or painful feelings
• Scorching or swelling occasionally

They usually appear after a few hours or days of exposure to cold and persist for one to three weeks. Women (assigned females at birth), those with low body weight, and those suffering from diseases like lupus are more likely to experience them. Chilblains regularly return each winter.¹

There are mostly two kinds:¹

• Idiopathic chilblains: these develop spontaneously in the absence of another illness
• Secondary chilblains: associated with diseases like lupus, circulatory disorders, or specific blood issues

Chilblains are uncomfortable and can interfere with day-to-day activities, but they are not life-threatening. The skin may deteriorate in extreme situations, resulting in ulcers or infections.¹

Smoking as a Risk Factor for Chilblains.

A systematic analysis (a detailed and organised review of all available research on a topic) of chilblain patients discovered that smokers were more likely to develop the disorder, particularly when additional risk factors were present.¹ A Mayo Clinic study of over 100 patients also recommended quitting smoking as part of successful treatment.² 

Doctors who treat chilblains frequently advise patients to avoid smoking, as well as cold and damp exposure.²  

So, why does smoking increase the risk? To understand this, consider how smoking affects the microcirculation, the body's smallest blood arteries consisting of arterioles, capillaries, and venules.

Blood vessel narrowing

Cigarettes contain nicotine, which causes blood vessels to constrict (become narrower) immediately. This means that less warm blood reaches the skin. In cold conditions, arteries naturally constrict to conserve heat. Smoking intensifies this impact, depriving toes and fingers of warmth and oxygen.^3,4,5 

Damage to the vessel lining

The endothelium, or inner lining of blood vessels, generally facilitates blood flow. Smoking harms this lining and lowers the generation of nitric oxide, which causes arteries to relax. Without it, the vessels remain narrow, resulting in poor circulation.^3,6 

Increased inflammation

Chilblains are a type of inflammatory reaction in the skin. Smoking causes inflammation throughout the body, making blood vessels more "sticky" to white blood cells. This could explain why skin biopsies (a test where a bit of skin or skin cells is removed and checked in a laboratory) from smokers with chilblains reveal increased inflammatory cells surrounding arteries.¹ 

Increased clotting

Smoking activates blood platelets, which can cause minor clots in the skin's microscopic arteries (arterioles). These clots further restrict blood flow, exacerbating chilblain lesions (injuries).³ 

Poor healing

 Once chilblains develop, smoking inhibits recovery. It limits oxygen flow, inhibits collagen formation, and slows tissue regeneration (the body’s way of growing new tissues to replace damaged ones). This is one reason why doctors frequently notice poorer healing and greater difficulties among smokers.² 

Passive Smoking and Vaping

It is not only active smoking that counts. According to studies, secondhand smoke impairs blood vessel function.⁶ Children who are exposed to household smoking may be at an increased risk. Newer items, such as e-cigarettes and heated tobacco, contain nicotine, which continues to restrict blood vessels and impair circulation.⁵ Although the overall danger is thought to be lower than regular smoking, the effect on chilblains has yet to be thoroughly investigated.⁵

Key things everyone involved should know

 Patients

• If you suffer from chilblains, quitting smoking is one of the most effective steps you can take
• Avoid cold, damp environments and keep extremities (arms or legs) warm and dry
• If quitting completely is difficult, even reducing smoking may help circulation

Doctors and Nurses

• Always ask about smoking in patients with recurrent chilblains
• Provide support and resources for smoking cessation
• Emphasise that quitting smoking helps not only the lungs and heart, but also the skin and blood flow

Families and Communities

• Parents who smoke should be aware that second-hand smoke can affect children’s circulation and possibly increase their risk of chilblains
• Community health campaigns in colder regions should include education about the effects of smoking on the skin

Public Health

• Campaigns about smoking usually focus on cancer and heart disease. Adding information about circulation problems like chilblains can make the risks more relatable for some people
• In countries with cold winters, awareness is especially important for people working outdoors, students, and older adults

Scientific findings on smoking as a risk factor for chilblains

• A study of patients with chilblains indicated that smoking was consistently associated with an increased risk. When diagnosing and treating chilblains, the authors recommended that a smoking history be obtained¹ 
• Mayo Clinic study: Among 104 patients, lifestyle changes such as staying warm and quitting smoking were the most effective therapies²  
• Independent research on smoking has found significant evidence that it lowers blood flow, destroys blood vessel lining, and hinders healing, all of which are associated with chilblains^3,4,5,6 

Together, this creates a clear picture: smoking directly aggravates the mechanisms that generate chilblains.

Future Directions

Further study is required to:

• Determine how much smoking raises the risk in comparison to nonsmokers
• Investigate whether stopping smoking reduces chilblain recurrence
• Investigate the impact of vaping and other nicotine products on chilblains
• Consider the combined impact of smoking and other risk factors such as being underweight, eating poorly, or having an autoimmune condition

Summary

Chilblains are a reminder of how vulnerable the human body is to environmental changes, and how our lifestyle choices can either protect or harm our natural defences. Although chilblains are frequently overlooked as a minor winter concern, they can cause discomfort, worsen quality of life, and even significant problems if left untreated. The study presented in this article demonstrates that smoking greatly increases the risk and severity of chilblains. Nicotine and other compounds included in tobacco smoke harm blood vessels, limit oxygen delivery to tissues, and hinder the body's natural capacity to regulate temperature and recover. These effects combine to increase smokers' susceptibility to cold-related vascular (blood) disorders, such as chilblains.

It is worth noting that the association between smoking and chilblains does not only apply to direct smokers. Passive smokers may also be at risk since secondhand smoke has similar effects on circulation and blood vessel function. While chilblains are rarely life-threatening, they can indicate poor circulation and vascular health. This makes them particularly essential in the broader context of public health. Itchy, swollen fingers or toes in the winter may indicate more serious complications if smoking is not stopped.

The good news is that prevention is possible. Quitting smoking, staying warm in chilly situations, eating a healthy diet, and taking care of your skin can all help minimise your risk of having chilblains. For healthcare providers, this link provides an opportunity to urge people to quit smoking by emphasising not only long-term risks like cancer and heart disease, but also immediate, apparent difficulties like chilblains.

Finally, the link between smoking and chilblains demonstrates how simple lifestyle choices can have a direct impact on health. By lowering smoking and raising awareness, we can safeguard vascular health and avoid unnecessary pain during the colder months.