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Abstract

Objectives

To study constitutional and behavioral risk factors for chilblains in patients at Abbottabad and Sialkot, Pakistan.

Methods

One hundred patients and matched controls completed a single-page, close-ended questionnaire which included demographic data and questions related to possible constitutional and behavioral risk factors for chilblains. Computer program SPSS-10 was used to manage and analyze the data. Risk factors were identified statistically by determining odds ratios and 95% confidence intervals using multivariate analysis.

Results

There were an equal number of male and female respondents in each group. Age of the patients and controls ranged from 2 to 80 years with a mean of 24.51 ± 16.02. Twenty-six patients and 3 controls had a positive family history for chilblains (odds ratio = 9.33); 42 patients and 14 controls reported a history of constipation (odds ratio = 2.69); 32 patients and 8 controls had a history of either numbness or tingling of fingers or toes (odds ratio = 2.93); 55 patients and 45 controls led sedentary lifestyles (odds ratio = 1.27); 85 patients and 58 controls consumed a low number of cups of tea daily (odds ratio = 3.20); 65 patients and 29 controls frequently washed their hands and/or feet (odds ratio = 4.93); and 56 patients and 33 controls had occasional sun exposure during winter months (odds ratio = 2.08).

Conclusion

Significant risk factors for the development of chilblains for people at Abbottabad and Sialkot included a history of chilblains in first-degree relatives, numbness and tingling sensations of fingers or toes, frequent hand or feet washing, and lower tea consumption during winter months.

Keywords

chilblains Pakistan perniosis cold inujury

Introduction

Chilblains or perniosis is a localized disease of abnormal sensitivity to cold, which presents as inflammatory, erythematous or violaceous, pruritic or painful acral lesions. It develops in certain individuals after prolonged exposure to nonfreezing temperatures and damp conditions.¹^-3 In normal individuals, moderate cold exposure induces cutaneous vasoconstriction followed by vasodilatation in an attempt to maintain perfusion. However, in individuals afflicted by chilblains a persistent cold-induced constriction of the large cutaneous arterioles and persistent dilatation of the smaller, more superficial vessels occurs.⁴

The risk, nature, and magnitude of chilblains like other cold injuries depend largely on the interaction of weather conditions, protective measures, and metabolic heat production.⁵ Interindividual differences exist with respect to the relative contribution of metabolic and insulative adaptation to cold^6,7 and probably certain constitutional and behavioral factors.⁸ Low body mass index (BMI),^9,10 outdoor occupation,⁹ previous cold injuries,¹¹ and positive family history⁴ have been reported as risk factors for chilblains and other localized cold injuries in various studies. The purpose of this study was to identify risk factors for chilblains from Abbottabad and Sialkot, Pakistan.

Weather station Kakul (Abbottabad) is located at 34.18°N, 73.25°E at an elevation of approximately 1284 meters (4212 feet) above sea level. Average temperatures range from 4.8°C to 15.0°C with an average rainfall of 136.7 mm (5.38 inches) during the winter months of December to March.¹² Sialkot (32°N, 74°E) is 255 meters (836 feet) above sea level. Average temperatures of Sialkot range from 8.0°C to 21.7°C with an average rainfall of 41.1 mm (1.65 inches) from December through March.¹³

Material and Methods

This study was conducted simultaneously at the dermatology departments of Combined Military Hospitals, Abbottabad and Sialkot during the winter months of December 2006 to March 2007. Patients attending the dermatology outpatient departments of these hospitals with persistent painful or pruritic, erythematous or dusky erythematous lesions of less than 3 weeks duration and involving digits or other peripheral parts of the body were diagnosed with chilblains and were included in the study. Patients having a past or present history of collagen vascular disease, acrocyanosis, or peripheral vascular disease were excluded from the study. A total of 100 patients fulfilling the selection criteria were registered for the study. Another group of 100 age- and gender-matched individuals reporting to the dermatology outpatient departments of these hospitals with unrelated dermatological problems or as attendants with their families was included in the study simultaneously as controls. Patients and controls were generally of the same socioeconomic background. Recruitment of patients and controls was done using a nonprobability, convenience sampling technique. The participation of both patients and controls was voluntary and none declined to participate as it was a single-encounter study. Pulse, weight, and height of all patients and controls were recorded and BMI was calculated. The questionnaire was close-ended and not pretested. It included demographic and personal data, including age and gender. The rest of the questions included possible constitutional and behavioral risk factors such as a history of numbness or tingling in fingers or toes, complaints of constipation, family history of chilblains, frequency of washing hands and feet, frequency of hot drink intake per day, sun exposure, and self-reported lifestyle (active or sedentary). Washing of hands and feet was defined as frequent when hands and/or feet were washed more than 5 times per day. Exposure to direct sunlight for less than 30 minutes per day was arbitrarily defined as occasional exposure. Intake of 2 or less cups of milk-added tea per day during winter months was considered low consumption of tea.

Computer program SPSS 10 was used to manage and analyze the data. Descriptive analysis was performed for age, sex, pulse rate, and BMI. Results were expressed as numbers and mean ± SD. Independent samples t test was used to calculate P values for numeric variables such as BMI and pulse rate to compare patients and controls. Chi-square analysis was applied to compare proportions. A P value of <.05 was chosen as significant. Risk factors selected for the study (ie, family history of chilblains, complaints of constipation, numbness and/or tingling sensations in fingers or toes, frequency of washing hands and feet, frequency of hot drink intake per day, sun exposure, and lifestyle active or sedentary) were assessed statistically by determining odds ratios and 95% confidence intervals using multivariate analysis. Odds ratios of 3.0 and above were chosen as indicating a statistically significant association with the effect (ie, development of chilblains), values between 2.0 and 2.9, as a moderate association, and values less than 1.0 as insignificant association.

The study was approved by the Ethics and Scientific Committee of the hospitals.

Results

One hundred individuals each were recruited into the patient group and the control group. Since there were 100 respondents in each group, the raw numbers are equal to the percentages (percentages therefore not shown). The number of male and female volunteers was equal. Ages of the patients and controls ranged from 2 to 80 years with a mean of 24.51 ± 16.02. Seventy-nine patients were ≤30 years of age and 21 patients were over 30. BMI of the patients ranged from 10.00 to 34.50 with a mean of 20.66 ± 4.13, and that of controls ranged from 12.70 to 34.60 with a mean of 20.92 ± 4.30 (P = .66). Pulse rates of patients ranged from 54 to 120 beats per minute with a mean of 85 ± 13, controls ranged from 64 to 120 beats per minute with a mean of 85 ± 11 (P = .74). Twenty-four patients presented in December, 43 in January, 21 in February, and 12 in March.

Twenty-six patients and 3 controls had a positive family history for chilblains (odds ratio = 9.33). Forty two patients and 14 controls complained of having constipation (odds ratio = 2.69). Thirty two patients and 8 controls had a history of either numbness or tingling of fingers or toes (odds ratio = 2.93) (Table).

Table

Factors associated with chilblains as identified by multivariate analysis (n = 100 + 100)

Variable	Patients	Controls	Odds ratio	95% Confidence interval
Positive family history	26	3	9.33	2.40-36.14
Constipation	42	14	2.69	1.14-6.32
Numbness/tingling of fingers	32	8	2.93	1.06-8.05
Less tea consumption	85	58	3.20	1.43-7.17
Frequent hand washing	65	29	4.93	2.41-10.07
Occasional sun exposure	56	33	2.08	1.02-4.25

Fifty-five patients and 45 controls reported leading a sedentary lifestyle (odds ratio = 1.27). Tea intake among patients was 0 to 6 cups per day with a mean of 1.53 ± 1.12, whereas the intake among controls was 0 to 10 cups per day with a mean of 2.30 ± 1.56 (P <.05). Eighty-five patients and 58 controls consumed up to 2 cups of tea per day. whereas 15 patients and 42 controls consumed more than 2 cups of tea per day (odds ratio = 3.20). Sixty-five patients and 29 controls reported that they washed their hands frequently (odds ratio = 4.93). Fifty-six patients and 33 controls were only occasionally exposed to the sun, whereas 44 patients and 67 controls reported sitting in the sun almost daily for a few hours (odds ratio = 2.08) (Table).

Discussion

Chilblains or perniosis is a localized cold injury usually confined to acral parts of the body. Although transient and self-limited the sufferer may be incapacitated because of pain or itching over the affected areas until healing takes place over a few weeks. The disease has a tendency to recur in subsequent cold weather.¹⁴ As it is a preventable disease, an attempt has been made in this study to identify various constitutional and behavioral risk factors for chilblains.

The potential risk factors included in this study were those pertaining to constitutional factors such as BMI, pulse rate, constipation, family history, and numbness or tingling sensations of fingers or toes, as well as behavioral practices, such as lifestyle (whether sedentary or active), tea intake, frequency of hand washing, and sun exposure during winter months.

Many researchers have reported that low body weight or low BMI has an association with chilblains⁹ ^,10,14,15 in contrast to the findings of this study where statistical analysis of the data did not show BMI to be a risk factor. Although exact pathogenesis is unknown, it has been proposed that thin body habitus may somehow be associated with increased cutaneous vasoreactivity.¹³ Pulse rate was also not found to have an association with chilblains, although pulse volume may have an important association, which we did not assess objectively. It may be worthwhile to determine the association of pulse volume with chilblains in future studies.

Development of chilblains was found to be strongly associated with a history of the disease in first-degree relatives. Although this finding is in concordance with previous studies,^4,16 it may not be possible without objective assessment to state with certainty if it is because of genetic predispositions or exposure to similar environmental factors in these patients.

Similarly, numbness and/or tingling sensations of fingers or toes were also found to be associated with chilblains as a risk factor. The common link here again probably is altered neuronal response of peripheral nerves. However, we could not assess this symptom precisely; therefore, this association needs careful and objective assessment as a possible association with development of chilblains.

We also noted a trend for a history of constipation being associated with development of chilblains, although this association did not reach statistical significance. Constipation is a common symptom affecting 2% to 27% of general populations in Western countries,¹⁷ and is probably more common in the Indian subcontinent.¹⁸ While there are a multitude of causes for constipation, neuropathy has been suggested to be one factor.^17,19 There may be a common pathogenetic link between constipation and an abnormal autonomic neuronal activity, leading to an altered vasomotor response of the acral parts of the body to cold exposure in patients suffering from chilblains. The possible association between constipation and chilblains needs to be assessed more objectively.

Besides constitutional factors, certain behaviors were also found to have a possible association with development of chilblains. Although physical activity has been recommended to help avoid certain cold injuries,²⁰ the association between a self-reported sedentary lifestyle and development of chilblains was not found to be significant in this study. Racial differences in the peripheral arterial response to exercise have been documented.²¹ However, such a study has not been carried out in any Asian population to determine if there is any altered vasodilatory response of peripheral vessels to adrenergic stimulation after physical exercise.

Milk-added tea is a common drink in Pakistan. Many people consume it year-round, although its consumption increases during winter months. Tea is thought to increase skin temperature via an enhanced vasodilatory response, possibly related to its constituent flavonoids,²² and it has been recommended as part of treatment during the rapid rewarming phase of therapy in cold injuries.^23,24 Although it has been shown that addition of milk counteracts the vasodilatory effects of tea,²⁵ lesser consumption of milk-added tea during winter season was significantly associated with a risk of developing chilblains in our study. Frequent hot tea consumption during the winter season may protect a person from localized cold injuries by helping to keep the body warm, by warming the fingers holding the cup, and possibly by other beneficial mechanisms.

Washing one's hands after visiting the toilet and before eating is considered hygienic and, for many, is considered essential in Pakistani culture, although not everyone practices this. Some individuals wash their hands and feet 2 to 5 times each day for prayers but do not regularly dry them. Frequent hand or feet washing as defined in this study was found to be significantly associated with chilblains. Repeated washing followed by evaporation leads to skin surface cooling, which causes cold-sensitive afferents to activate sympathetic nerves to release norepinephrine, leading to a local cutaneous vasoconstriction.²⁶ Thus, frequent washing of hands or feet may predispose individuals to development of chilblains.

Lower levels of sun exposure during cold weather showed a trend towards association with development of chilblains in our study, although it did not reach statistical significance. Approximately three fourths of the population of Pakistan lives in rural areas and either work outdoors or have sufficient time to relax in the sun between their routine activities. Although a study conducted by Langtry and Diffey²⁷ suggested that ultraviolet phototherapy was of no value in preventing chilblains, their protocol involved exposing volunteers' limbs to ultraviolet radiations in autumn in an attempt to prevent later chilblains during the course of winter. We suggest that the value of sun exposure on preventing chilblains be studied more objectively during the season when individuals are likely to develop the disease.

Chilblains, like other localized cold injuries, is largely a preventable disease. Knowing risk factors for the disease would be beneficial for its prevention. Risk of chilblains and other cold injuries can be decreased by education, knowledge, and appropriate behavior.

This study has weaknesses and limitations. Responses to some of the questions in the questionnaire were completely subjective and we did not assess some variables objectively. We relied on individuals' self-reporting on many of the variables (such as constipation, lifestyle, and degree of sun exposure). We suggest further studies involving precise definition and objective measurement of potential risk factors for developing chilblains.

Conclusion

Individual factors are important in the risk of developing chilblains. A history of chilblains in first-degree relatives, complaints of numbness and tingling sensations of the fingers or toes, and the behavioral factors of frequent hand and foot washing and lower consumption of tea during winter months appear to be significant risk factors for chilblains in patients at Abbottabad and Sialkot, Pakistan.

Footnotes

Questionnaire

CONSTITUTIONAL AND BEHAVIORAL RISK FACTORS FOR CHILBLAINS

S/No:

Date:

Status: Patient/Control

Age

Gender: Male/Female

Weight: Height: BMI:

Pulse:

Family H/O Chilblains: Yes/No

H/O finger/toe numbness: Yes/No

H/O Constipation: Yes/No

Hot drinks intake: (Number of cups/day^⁎)__________

H/O Hand/Feet washing: Frequent^⁎⁎/Infrequent

Life style: Active/Sedentary

UV Exposure: Sufficient/Insufficient^⁎⁎⁎

⁎

Consumption of up to 2 cups of tea per day during winter months

⁎⁎

Washing hands/feet more than 5 times per day

⁎⁎⁎

Exposure to direct sunlight for less than 30 minutes per day

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Constitutional and Behavioral Risk Factors for Chilblains: A Case-Control Study From Pakistan

Abstract

Objectives

Methods

Results

Conclusion

Keywords

Introduction

Material and Methods

Results

Discussion

Conclusion

Footnotes

Questionnaire

References