Cold Hands, Warm... Differential?

Last week, Dr. Derrick Tao presented a case of an elderly woman who presented with subacute progressive discoloration of her fingertips after cold exposure. Raynaud’s phenomenon, obviously. But wait! It lasted for several weeks and she also had tender ulcers and splinter hemorrhages! Hmmmm… After a long and extensive infectious and rheumatologic work-up, she was diagnosed with chilblains!

Wait a minute, chil-what? Chilblains, or pernio, is cold-induced damage to the capillary beds in the skin causing erythema, pruritus, inflammation, and even tissue damage. It is a benign condition in and of itself, but can be associated with more serious diagnoses. It is treated with – you guessed it –gloves! It is often confused with Raynaud’s, and a patient may have both simultaneously, but the key difference is that Raynaud’s phenomenon is typically acute and readily reversible vasospasm (lasting minutes), whereas pernio involves more prolonged vasospasm causing chronic tissue changes (lasting weeks). You should not have skin lesions (ulcers, nodules) with Raynaud’s alone.

Thanks to Derrick and the Clinical Problem Solvers for this great discussion and diagram of alarm features of Raynaud’s and the differential that results.

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When’s the last time you examined your patient’s nails on admission? We ended report with a little manicure time - see below for a fun review of different nail changes and disease associations!

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