Perniones T69.1

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 30.05.2024

Synonym(s)

Chilblains; frostbite; Frostbite; frost-nip; Perniosis

Definition
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Frequent abnormal tissue reaction occurring in persons with the appropriate disposition, with reversible and very changeable inflammatory skin changes, which can occur even with moderate exposure to cold.

Etiopathogenesis
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Mostly vegetatively disturbed vascular function with insufficient adaptation to external temperature conditions (outside temperatures slightly above 0 °C, especially in cold and wet climates, also in cold humid work, e.g. in butchery professions), but also in local or systemic infections (tuberculosis patients).

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Manifestation
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Occurs mainly in female adolescents or adults with acrocyanosis. Frequently there is general obesity or pasty habitus. Seasonal accumulation mainly in spring and autumn. Occurrence in connection with occupational exposure to cold (butchers, cold store workers, soldiers) or in homeless people is not uncommon. Increasingly, frostbite is occurring among alpinists.

Localization
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Dorsal sides of the fingers and toes, nose, lower leg, knee area.

Clinical features
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In the interval little conspicuous, laminar, livid redness, which changes to blue-reddish, possibly blue or reddish-brown (purple component), pasty, sometimes painless but also clearly painful plaques or nodules when the temperature changes. The duration of the changes varies, ranging from hours to several days to weeks. Itching or burning may occur when the skin warms up. Blistering and ulceration are possible. S.a. Perniosis follicularis, spring perniosis, autumn perniosis.

Notice! An apparently healthy red complexion can be an expression of chronic cold damage.

Histology
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Capillary dilatation exists in the corium. Edema is detectable in the upper corium. Larger vessels are wall thickened and filled with thrombi. Lymphohistiocytic infiltrates are perivascular.

Differential diagnosis
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Chilblain lupus; erythema nodosum; sarcoidosis; erythema exsudativum multiforme.

Complication(s)
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Secondary infections, ulcerations, scars.

External therapy
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In the acute phase supply of heat and/or hyperemic ointments. In case of strong inflammatory symptoms, short-term potent glucocorticoid extracts such as 0.05% clobetasol cream (e.g. R054, dermoxin), 0.1% mometasone cream (e.g. Ecural), if necessary under occlusion.

Internal therapy
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Systemic therapy can be considered in the case of very pronounced clinical symptoms, e.g. with interval therapy with iloprost (0.5-2.0ng/kgKG/min.
Furthermore, a trial with pentoxifylline (e.g. Trental) 2 times/day 400 mg p.o. can be initiated.

Progression/forecast
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Very variable course; recurrences with exposure to cold. Improvement at a higher age is possible.

Prophylaxis
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Especially in the transitional seasons, protection against cold and wetness by wearing suitable clothing, warm shoes! Use of pocket ovens! Active vascular training in the sauna, Kneipp cures, underwater massages, foot baths with alternating temperatures, sports.

Phytotherapy external
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Benedictine herb used to be used externally, see Cnici benedicti herba,

in empirical medicine also Fagopyri herba and Ratanhiae radix

Note(s)
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Chronic cold damage caused by recurrent pernions may fall under BK number 5101 of the BVK plant.

Literature
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Gomes MM et al (2014) Perniosis. BMJ Case Rep doi: 10.1136/bcr-2014-203732
Johnson-Arbor K et al (2014) Digital frostbite. N Engl J Med doi: 10.1056/NEJMicm1310126
Kemper TC et al (2014) Frostbite of both first digits of the foot treated with delayed hyperbaric oxygen:a case report and review of literature. Undersea Hyperb Med 41:65-70
Müller M et al (2007) Recurrent perniosis at the base of a congenital acrocyanosis. Dermatology at work and in the environment 55: 28-34
Ohatee MA et al (2014) "Salt ice dare": a previously undescribedmechanism
of rapid frostbite injury. J Plast Reconstr Aesthet Surgery 67:e248-249