Hugh is a 40-something professional in good health apart from a chronic, recurring, intermittent condition that affects him several times a year. In cool and damp weather, he gets severe cold, discomfort, redness, swelling and itching in his toes which may last for hours. It is not easily treatable, and goes away just as suddenly as it comes.
He suffers from chilblains, or pernio, a condition that affects circulation in the extremities, most often the toes, but also fingers, nose and earlobes. The itching can be intense and in quiet moments between clients he can be seen tearing at his toes in an attempt at relief, but this is a vicious circle as short-lived comfort is usually followed by even more unpleasant feelings.
Chilblains are poorly understood, falling in a medical no-man's land between diseases of the circulation, skin problems and collagen disorders (diseases, such as rheumatoid arthritis, which affect connective tissue). They have characteristics common to many of these conditions, but as they are not life-threatening, research has been limited and treatment unsatisfactory.
What is known is that in cold temperatures, although the main arteries remain open, small blood vessels in the skin of hands and feet close down temporarily, leading to the characteristic symptoms. Gradual reopening of these arterioles and capillaries leads to relief. Biopsies of chilblains have sometimes shown evidence of vasculitis (inflammation of blood _vessels) and blood tests in some patients can show abnormalities common to collagen diseases such as lupus and scleroderma.
This is not the full story, however, as in these conditions vasculitis can be progressive and lead to tissue injury and gangrene. Although the word pernio is related to "pernicious" with the same suggestion of destruction, chilblains are generally benign and most sufferers do not develop lasting damage. Persistent coldness, signs of ulceration and progressive pain may suggest other serious disorders, such as peripheral vascular disease or diabetes, and your doctor's advice should be sought urgently.
Chilblains may be an occupational hazard in for those working outdoors, such as farmers and road workers. There may also be a hereditary or genetic element, to chilblains, as Hugh's father suffered during his youth and his teenage son currentlygets even more severe attacks than Hugh.
The more treatments that are advocated for any condition, the less likely any of them is to be more effective than the others, and the treatment of chilblains is typical of this. In the absence of definite understanding of the genesis of the condition, treatment is often empirical on a trial and error basis.
Over the years, numerous drugs, hormones and vitamin preparations such as nicotinic acid, calcitonin, thymoxamine and vasodilators (drugs which widen blood vessels such as prazosin and nifedipine) have been tried with varying success. Of the latter, nifedipine, which is used in heart disease and high blood pressure, has been shown to increase blood flow in the small blood vessels of the skin, but side-effects such as facial flushing and ankle swelling have limited its usefulness.
Topical preparations (applied directly to the skin) such as steroid and other creams have also been used with predictable results: as temporary relief may be obtained from rubbing the skin and stimulating circulation, it is hard to assess whether the ingredients of creams have any intrinsic therapeutic value. There are also many homeopathic, herbal and complementary remedies for chilblains, which work anecdotally, but these have not been subjected to the same scientific rigour as rigouond tpharmaceuticals and should be used cautiously.
Prevention is better than cure. Avoidance of extreme cold is advisable, patients should not smoke, and warm socks and comfortable footwear are important. Direct warming by hot water bottles or application of heat sources is dangerous and may lead to burns and ulceration; gradual re-warming is much safer. Regular exercise is of benefit.
Hugh has tried many approaches to treatment but finds nothing of lasting or long-standing value. He manages by surreptitiously twiddling his toes under the desk, which boosts circulation and relieves the desire to scratch, and has learnt to live with his condition.
He is not yet desperate enough to try one extreme remedy by which a close relative swears by - that of immersing his feet in his own urine!