Case Reports

Ice Pack–Induced Perniosis: A Rare and Underrecognized Association

Author and Disclosure Information

Perniosis, or chilblain, is characterized by skin lesions that occur as an abnormal reaction to exposure to cold and damp conditions. It can present as an idiopathic dermatosis or in association with an underlying connective tissue or autoimmune disease. Differentiation by histopathologic examination is controversial. Herein, we report a unique case of a 73-year-old woman who developed acquired perniosis on the buttocks from the use of ice packs to treat chronic low back pain.

Practice Points

  • Ice pack-induced perniosis is a rare condition that can occur in patients using long-term ice pack therapy.
  • This entity histopathologically mimics cutaneous lupus erythematosus and can present a diagnostic challenge.
  • A thorough clinical history and awareness of this diagnosis is essential for diagnostic accuracy.


 

References

Perniosis, or chilblain, is characterized by localized, tender, erythematous skin lesions that occur as an abnormal reaction to exposure to cold and damp conditions. Although the lesions favor the distal extremities, perniosis may present anywhere on the body. Lesions can develop within hours to days following exposure to temperature less than 10°C or damp environments with greater than 60% humidity.1 Acute cases may lead to pruritus and tenderness, whereas chronic cases may involve lesions that blister or ulcerate and can take weeks to heal. We report an unusual case of erythematous plaques arising on the buttocks of a 73-year-old woman using ice pack treatments for chronic low back pain.

Case Report

A 73-year-old woman presented with recurrent tender lesions on the buttocks of 5 years’ duration. Her medical history was remarkable for hypertension, hypothyroidism, and lumbar spinal fusion surgery 5 years prior. Physical examination revealed indurated erythematous plaques with areas of erosions on the left buttock with some involvement of the right buttock (Figure 1).

Figure1

Figure 1. Ice pack–induced perniosis presenting as indurated erythematous plaques with erosions on the buttock in a 73-year-old woman with chronic low back pain.

After a trial of oral valacyclovir for presumed herpes simplex infection provided no relief, a punch biopsy of the left buttock was performed, which revealed a cell-poor interface dermatitis with superficial and deep perivascular and periadnexal lymphocytic infiltrates (Figure 2). Perieccrine lymphocytes were present in a small portion of the reticular dermis (Figure 3). The patient revealed she had been sitting on ice packs for several hours daily since the lumbar spinal fusion surgery 5 years prior to alleviate chronic low back pain.

Figure2

Figure 2. A punch biopsy revealed superficial and deep perivascular and periadnexal lymphocytic infiltrates (H&E, original magnification ×4).

Figure 3. Perieccrine lymphocytes were noted in a small portion of the reticular dermis (H&E, original magnification ×40).

Based on the clinicopathologic correlation, a diagnosis of perniosis secondary to ice pack therapy was made. An evaluation for concomitant or underlying connective tissue disease (CTD) including a complete blood cell count with sedimentation rate, antinuclear antibodies (ANAs), serum protein electrophoresis, and serum levels of cryoglobulins and complement components was unremarkable. Our patient was treated with simple analgesia and was encouraged to avoid direct contact with ice packs for extended periods of time. Because of her low back pain, she continued to use ice packs but readjusted them sporadically and decreased frequency of use. She had complete resolution of the lesions at 6-month follow-up.

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