Chilblains of the feet and hands
Identification of Issue
Last week, we had an admission of interesting diagnosis that I have never encounter before. An 11-year-old, male patient with history of vasculitic autonomic neuropathy diagnosed at University of Michigan Hospital by nerve biopsy, presented to the ED with pain in his hands and feet for the last 2 days and flare up of "Chilblain" symptoms. No signs of swelling or change in color, no rash, no erythema, No lesion, no fever, and no change in his walking. He was admitted to the floor for IV steroid and pain management. When we received the sign-out from the ED doctor on this case; I was wondering what “chilblains” means and how I can manage it.
The term chilblains is a descriptive word usually referring to an idiopathic medical condition, often cold-induced vasculopathy characterised by dusky red-purple nodules over skin of the hands and feet (Collins, Arnold, & Kissel, 2013). Chilblain is a clinical diagnosis; therefore, it is important to obtain a detailed history and do a comprehensive physical examination to exclude associated conditions, such as systematic disease or connective tissue disorder. Furthermore, full laboratory workup for a patient with chilblains should be done to exclude any systemic or autoimmune disorders, including the following lab tests: complete blood count with differentia, antinuclear antibody screen, cold agglutinin, cryoglobulin, cryofibrinogen and antiphospholipid antibody pane. Moreover, nerve biopsy is crucial for definitive diagnosis of a patient with suspected vasculitic neuropathy that leads to chilblains; a histologic diagnosis of definite vasculitic neuropathy requires inflammation within the vessel wall and signs of active or chronic vascular damage (Larkins & Murray, 2013). The fundamental histopathologic findings in equestrian chilblain show a relatively dense superficial and deep perivascular and periadnexal lymphocytic infiltrate with foci of extension into the adipose tissue (Yang et al., 2013). There are a variety of pharmacological options available for treatment of chilblain. The treatment of chilblain depends on the severity and associated symptoms. Most cases of chilblains will resolve spontaneously over the course of 1–2 weeks (Yang et al., 2013). Other cases particularly those associated with significant discomfort or pain need more vigorous treatment before developing of other local symptoms, such as skin lesions. The most commonly reported treatmens for chilblain being nifedipine, prazosin and oral corticosteroids (Collins et al., 2013; Yang et al., 2013).
We approach this case by starting Methylprednisolone 500 mg IV BID for 3 days according to Neurologist recommendations. I agreed with our team plan; however, this patient could be managed as an outpatient with oral steroids, I did not see any necessity that we should admit this patient because he is stable with no signs of erythema or lesions. In my literature review regarding managing vasculitis and chilblain symptoms, I found that the most effective and efficient treatment regime was a short course of oral prednisolone (3–5 days) or/and NSAIDS over 1–2 weeks to control associated pain.
In conclusion, chilblain is abnormal skin reaction to cold due to vasculitis which can cause itching, red patches, swelling and blistering on feet and hands. The most important part of chilblains diagnosis are a thorough history, physical examination, lab tests, and nerve biopsy which would reveal inflammation within the vessel wall and signs of active or chronic vascular damage; it has been shown that corticosteroids appears to be the most appropriate treatment of chilblains. As nurse I should explain the disease process to the family and provide instructions regarding limiting further cold exposure and avoid rapid changes in temperature by wearing gloves, hats, appropriate footwear in very cold climates with unavoidable cold exposure.