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Chilblains: An evidence-based analysis of pharmacologic options
P. Azevedo1, J. Neto2, M. L. Torres3; 1USF Fânzeres, Porto, Portugal, 2USF S. João de Sobrado, Porto, Portugal, 3USF Viver Mais, Oporto, Portugal. From WONCA Conference - Vienna
Quote:
Introduction
Chilblains, also known as erythema pernio or perniosis, consist of inflammatory concise lesions, caused by excessive cold and humidity exposition, in susceptible individuals. They represent a worldwide problem, with great social impact, largely recognized in the Primary Care setting. We could not access Portuguese epidemiologic data, but several studies in other nearby countries reveal an incidence of 2 to 6% of general population.
Objectives
Review the existent evidence concerning the treatment of chilblains.
Methodology
We performed a research of data in Evidence Based Medicine websites, using as key-words (MESH terms): “chilblains” and “erythema pernio”. Articles were limited to English, Spanish and Portuguese and published from January of 1980 to the present date. The selection process was made through abstract evaluation, and we aimed to include original randomized studies, meta-analysis and case reports, considered to be pertinent on this theme. We excluded studies that were not related to the treatment of chilblains, or were related to other childblains comorbidities (ex. Lupus), and all paper works we could not access integrally. To attribute a level of evidence, we used the SORT Scale (Strenght Of Recommendation Taxonomy) of American Academy of Family Physicians.
Results
We found 8 articles with reference to 4 therapeutic interventions: vasodilators (diltiazem, nifedipine and pentoxifilin), ultraviolet irradiation (UV), vitamin D, and corticosteroids. Concerning the use of vasodilators, it was found to have a beneficial effect on symptoms, with an evidence level of B (with better results using nifedipine). Corticosteroids have also shown efficacy, but they appear to be less effective than vasodilators and we found less evidence supporting its use, so it was attributed an evidence level of C. Vitamin D and UV did not show to change the clinical course of disease, and both this treatments received an evidence level of B.
Conclusion
Chilblains are a frequent complain and cause pain and disability to its sufferers.
Vasodilators are often the first pharmacologic option, and data collected in this review work, came to support this attitude, since it was the therapeutic intervention that has shown to achieve the best results, with greater evidence supporting the use of nifedipine.
Chilblains: An evidence-based analysis of pharmacologic options
P. Azevedo1, J. Neto2, M. L. Torres3; 1USF Fânzeres, Porto, Portugal, 2USF S. João de Sobrado, Porto, Portugal, 3USF Viver Mais, Oporto, Portugal. From WONCA Conference - Vienna
Dear Admin
Do we have any information on the SORT scale please - I would like to understand how treatments that show a benefit and treatments that show NO benefit can be on the same level on a scale of evidence - thanks
Could it be that there is the same level of evidence showing that the vasodilators work as there is showing that UV and vitamin D don't? In other words the level of evidence has nothing to do with the efficacy of the treatment, just with how confident they are with saying that it either does or doesn't work. That would be my guess.
Do we have any information on the SORT scale please - I would like to understand how treatments that show a benefit and treatments that show NO benefit can be on the same level on a scale of evidence - thanks
They can be scored the same in terms of evidence level because the same level of evidence exists for the testing of their efficacy, this does not mean they are equally efficacious. For example, treatment A has been investigated in 6 high quality placebo controlled trials which have shown that this treatment is no better than a placebo; treatment B has received attention in 6 placebo controlled trials which have shown treatment B to be better than a placebo- same level of evidence for both treatments but one is demonstrably more efficacious than a placebo, while the other is not. Hope that makes sense. Here's some stuff on SORT: http://www.aafp.org/afp/2004/0201/p548.html http://www.stfm.org/fmhub/fm2004/February/Barry141.pdf
Practising on the sunny Gold Coast,Queensland Australia we still have patients presenting with chilblains every Winter. One of our issues is that our patients do not believe we can have a "winter" and may rug up the upper body but not their feet! This may be either systemic or occupation. During the Autumn I start dispensing 1mm plastazote innersoles to place under the shoe innersole + advice. Believe it or not we have one case of frostbite with a shopkeeper with scleroderma.
Cheers JO
I practice in Northern Costa Blanca in Spain and see far more Chilblains than I used to see when practicing in the UK. Houses tend to have poor insulation and tiled floors. About two years ago I had a patient with very sore chilblains, and decided to do some Low Level Laser to try to help with the pain. The results were very good not only did it stop the pain but also the chilblains resolved very quickly. Now I laser all chilblains and even open ones resolve much quicker than previously. I suspect that the local vasodilation and increased cell metabolisum is what´s happening.
Is anyone else using Laser on chilblains and what are your experiences?
Sounds interesting. The plastazote innersoles are used as a preventative and are very cost effective. I buy a sheet of approximately 1mx1m for $8 and and can dispense quite a few pairs.I tend to use the 1mm for women's shoes and 2mm for men's.
Background
Extreme sub-zero temperature in winters (15 °C to −25 °C), high velocity winds and wind-chill factor pose risk to those who resides at the high altitude environment to develop cold related injuries like chilblains and frostbite. The aim of this study was to study the patterns of chilblains in high altitude region like Ladakh.
Methods
The study was conducted at Dermatology outpatient department of Military Hospital, Leh from 1 Sep 2009 to 31 May 2010. Patients, satisfying clinical criteria for the diagnosis of chilblains were included into the study. Detailed history and thorough clinical examination was conducted. Complete blood count and Urine routine examination was carried out in every patient. Anti Nuclear Factor tests were carried out in only those who had history suggestive of connective tissue disease.
Results
Total 108 (5.75%) were diagnosed to have chilblains. Only a single case of chilblain was found in a local resident (p < 0.005). Family history of chilblains was present in 10 (9.2%) patients, there was recurrence in 12 (11.1%) and 21 patients (19.4%) were smokers. Most (63.8%) of the patients, had BMI between 20 and 22 kg/m2 (mean = 20.03 kg/m2; 95% CI = 19.68–20.38 and SD 1.82). 42.1% of cases of chilblains also had hyperhidrosis (p < 0.05).
Conclusion
In a HA area like Ladakh, the non-natives suffer maximum from chilblains. This could be explained by the protective genetic adaptability of natives to extreme cold environment and their protective life style against cold. Low body mass index (BMI) and hyperhidrosis are important associations for development of chilblains.
Chilblains Treatment
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