Frostbite is a term describing severe cold injury to the skin, soft tissue, and possibly deeper structures. Cold injury is most commonly seen in children, elderly individuals, mentally impaired individuals, substance abusers, distance and outdoor athletes in cold climates, and undomiciled persons without proper access to shelter or weather-appropriate clothing. Exposed areas such as the distal extremities, neck, chin, cheeks, nose, and ears are most often affected. Typically, the cold exposure occurs over minutes or hours, but even instantaneous exposure to cold metal can result in frostbite. At -2°C (28.4°F), cellular metabolism stops, proteins and enzymes are destroyed, and ice crystals form in the extracellular space, causing tissue damage and cell death.
Frostnip is the earliest sign of cold injury and presents with pain and pallor of the affected area, followed by numbness. With continued exposure, complete anesthesia will result. Many experts classify frostbite injuries as either superficial or deep, as this corresponds with a functional outcome. If a thumbprint may be left in the skin, the condition is more superficial, while deeper frostbite presents with skin that is hard to the touch. In deeper cases, deeper structures such as muscle, nerve, and bone may be affected.
The severity of tissue injury correlates with duration of exposure and lowest temperature. Pain and pruritus associated with frostbite can last as long as 8 weeks and 6 months, respectively. An increased sensitivity to cold may remain in areas of prior frostbite, and arthritis of acral joints may occur.
Predisposing factors for the development of frostbite include vascular conditions (such as peripheral vascular disease), diabetes, and the use of beta blockers. Additionally, peripheral neuropathy and Raynaud phenomenon, prolonged exposure to cold or high winds, restrictive clothing, and alcohol use predispose to frostbite. Prior damage from cold also increases the risk of frostbite. Athletes training at high altitude are at increased risk because of the combination of cold exposure and low ambient oxygen tension, which makes oxygen deprivation of affected tissues more severe.
Pediatric patient considerations: Children are at increased risk for frostbite because of their increased surface to body mass ratio. Younger children may not communicate symptoms at onset.
Frostbite in Adult
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Synopsis
Codes
ICD10CM:
T33.90XA – Superficial frostbite of unspecified sites, initial encounter
SNOMEDCT:
370977006 – Frostbite
T33.90XA – Superficial frostbite of unspecified sites, initial encounter
SNOMEDCT:
370977006 – Frostbite
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
A diagnosis of frostbite is usually based on a history of cold exposure and the clinical presentation. The differential diagnosis for frostbite includes the following:
- Frostnip – A form of cold injury that is milder than frostbite, as it involves only the superficial skin and subcutaneous tissue; the pain of frostnip usually resolves within 2-4 weeks.
- Raynaud phenomenon – A vasospastic disorder, sometimes associated with connective tissue disease, that is characterized by a specific sequence of color changes (white hypovascular skin, followed by cyanotic blue skin, followed by hyperemic red skin).
- Perniosis – A form of cold injury that is associated with a damp or humid environment and results in recurrent painful and/or pruritic, erythematous, violaceous papules or nodules on the fingers and/or toes.
- Pernio-like lesions associated with COVID-19
- Trench foot – A condition affecting the feet that, like pernio, is associated with cold and damp conditions; unlike frostbite, it does not require freezing temperatures.
- Bullous pemphigoid – Look for systemic, tense, and intensely pruritic blisters.
- Type 1 cryoglobulinemia
- Other causes of thrombotic vasculopathy, including sepsis, cocaine levamisole toxicity, cholesterol embolism, and others.
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
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References
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Last Reviewed:03/23/2022
Last Updated:05/09/2022
Last Updated:05/09/2022
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Frostbite in Adult