Why do his toes swell in the wintertime?

This otherwise healthy 62-year-old male presented for evaluation of his second episode of painful purplish swelling of his toes in the wintertime.

What could be the cause?

A. Celiac disease.

B. Leukocytoclastic vasculitis.

C. Cryoglobulinemia.

D. Cold agglutinins.

E. Macroglobulinemia.

(Answer and discussion on next page)

ANSWER—All of the above

Pernio or chilblains is an inflammatory skin condition presenting after exposure to cold as pruritic and/or painful erythematous-to-violaceous acral lesions. It may be idiopathic or secondary to an underlying disease. Pernio is due to an abnormal vascular response to cold exposure. The response of pernio to vasodilator drugs varies. Most patients with pernio present with a history of recurrent painful and/or pruritic, erythematous, violaceous papules or nodules on the fingers and/or toes. Most cases of pernio resolve within 2-3 weeks. 

The first step is to order a series of tests:

• CBC

• Sed rate

• Antiphospholipid 

• Cryoglobulins, cryofibrinogen, cold agglutinin

• ANA

• SPEP

• Hepatitis C

• Rheumatoid factor

In conclusion, all of the above are appropriate options. ■

References

1.St Clair NE, Kim CC, Semrin G, et al. Celiac disease presenting with chilblains in an adolescent girl. Pediatr Dermatol. 2006;23(5):451-454.

 2.Millard LG, Rowell NR. Chilblain lupus erythematosus (Hutchinson). A clinical and laboratory study of 17 patients. Br J Dermatol. 1978;98:497-506.

David L. Kaplan, MD, is clinical assistant professor of dermatology at the University of Missouri, Kansas, City School of Medicine and at the
University of Kansas School of Medicine. He practices adult and pediatric dermatology in Overland Park, KS.