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You are seeing a 14 year old boy who hiked in the snow yesterday with inadequate warm clothes and footwear. He has developed swollen violaceous papules and nodules on the toes of both feet. He states that the areas are itchy and sometimes have a burning sensation. Which of the following courses of action would be appropriate?
- Advise him to avoid further cold exposure and to use appropriate protective footwear
- Perform gentle rewarming in 37 to 39 degree Celsius water
- Perform a COVID-19 test
- Reassure him that this is a benign Raynaud phenomenon
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June 3, 2020 at 4:14 am
A) 1 and 3
The patient has symptoms of chilblains, also known as pernio. They are single or multiple symmetric edematous and erythematous or violacious plaques, papules, nodules, or macules, classically seen on fingers and toes. They develop 12-24 hours after cold exposure, and often result in itchiness or a burning sensation. They will usually resolve over 1-3 weeks with elimination of further cold exposure. Occasionally clinicians use topical corticosteroids or oral nifedipine in treating chilblains. Chilblains has been found to be a manifestation of COVID-19, often in an adolescent to young adult where this is the sole COVID-19 symptom. Rewarming would be a treatment for frostbite, which usually develops within minutes to hours of cold exposure and results in waxy white or cyanotic insensate skin. Raynaud phenomenon is a reaction to cold or stress causing digital arteries and arterioles to vasoconstrict, resulting in white, then blue, then red coloration. Changes are rapid and transient, over 15-20 minutes, and do not result in nodules and papules.