I’m going to start with the first question, “What’s your take on sudden onset of chilblains, first in the toes of one foot one day and then the toes of the other the next, after spending an hour in the cold, and this is in an eight-year-old who has mild psoriasis on the elbows but otherwise “healthy”?
Amy: Okay. I think a couple of things come to mind here. For those of you who haven’t heard of chilblains, or it’s also called pernio, these are small kind of areas of swelling on the skin. They generally occur specifically in the setting of cold temperatures, as was mentioned here. They tend to be itchy, quite uncomfortable, and they’re thought to be related to abnormal vascular responses, and, not surprisingly, patients with Raynaud’s are at an increased risk. Raynaud’s, remember, we think about also in association with autoimmune conditions, and you’re saying this is an eight-year-old who has psoriasis and is otherwise “healthy,” but I think you have to make an argument that if somebody has a manifestation of psoriasis, that does suggest an immune dysregulation. It’s an autoimmune disease. Already there’s something that’s out of out of balance.
I think the chilblains you have to think, okay, this is probably part of this R/t of inflammatory/immune dysregulation presentation, and while mild psoriasis maybe when it’s just in its very mild stages is largely there is a large cosmetic issue, and sometimes that can be the worst of it for people. But remember that if psoriasis is not appropriately managed, there is the potential that it can develop into psoriatic arthropathy, so, the arthritis that’s associated with psoriasis, and that can be quite debilitating. I actually do take psoriasis quite seriously, even if it is only the mild form of skin manifestations.
I’m not sure of the question here—is there something I think specifically about the chilblains? I think really what I’m thinking, is this is autoimmune disease? In an eight-year-old, I would still start with the Functional Medicine workup. I would look at what are the toxin exposures, is it looking like is this person should be gluten-free, dairy-free? I don’t like to put a an eight-year-old on an autoimmune Paleo diet. I think as they go into their teenage years you’re only going to get so much in terms of compliance, so figure out what a manageable dietary approach is for this eight-year-old, but I think at a minimum, gluten-free, and again look at the gut, look at nutrient sufficiency, look at toxic exposures. But I think even the mild psoriasis, again, I would I would take it quite seriously because you do not want this developing into psoriatic arthropathy. Hopefully that answers the question there.