Cold temperatures can cause lesions that may resemble a bacterial infection. A young female graduate presented with painful lesions on her toes along with discolouration after walking in cold temperatures!
A 23-year-old female presented to the clinic with complaints of discolouration of her toes bilaterally. The patient also complained of pain and blisters on her toes with intermittent pruritis. She revealed that her symptoms began after receiving a pedicure before a university event. On further inquiring, she told that after the pedicure she had been walking outdoors for a couple of hours in the cold weather. She had worn open-toed shoes. Moreover, the wind chill factor that evening had gone as low as 0° F. Past medical history was insignificant. She was a non-smoker and consumed less than 6 oz of alcohol in a week.
Physical examination revealed a well-appearing alert female weighing 55 kg and 160 cm tall. Her vital signs were normal and so were the cardiac and respiratory examinations.
Her primary care physician prescribed her cephalexin 500 mg orally for 10 days. However, even after 10 days, despite being compliant with the antibiotic, her symptoms persisted. She went to the emergency department for a second opinion where the ER physician diagnosed her with CA-MRSA. The physician prescribed her trimethoprim-sulfamethoxazole double-strength orally twice daily for 10 days.
However, unfortunately, she still had the same complaints. She was then referred to a dermatologist who performed a biopsy of the third toe of the left foot, and they decided to wait for the results before proceeding with any other treatment. The biopsy revealed a histological diagnosis of perniosis (chilblains). It is a vasospastic, inflammatory disorder secondary to exposure of unprotected skin to non-freezing, cold, and damp environment. the lesions may resemble lesions by methicillin-resistant Staphylococcus aureus (CA-MRSA).
Thereafter, the dermatologist counselled the patient to avoid exposure to extreme temperatures. Instead, she should wear warm footwear and avoid damp conditions. No other pharmacological treatment was necessary. Fortunately, her symptoms resolved 3 weeks later with conservative care and warmer ambient temperatures.
It is imperative for physicians to be aware of this disease to avoid misdiagnosis and undue treatment. Moreover, without the knowledge, the physicians won’t be able to counsel the affected individuals regarding the trigger of perniosis, hence the disease may not resolve until the patient avoids low temperatures and ensures adequate care.
Bohman, K.D., Papadimos, T.J., Gottwald, L.D. et al. Perniosis (chilblains) masquerading as CA-MRSA: a case report. Cases Journal 2, 6500 (2009). https://doi.org/10.1186/1757-1626-2-6500