Frostbite in Adult
Alerts and Notices
SynopsisFrostbite 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.
T33.90XA – Superficial frostbite of unspecified sites, initial encounter
370977006 – Frostbite
Differential Diagnosis & PitfallsA 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.
Drug Reaction DataBelow 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.
Patient Information for Frostbite in Adult
OverviewFrostbite is freezing of the skin that occurs due to exposure to cold temperatures. Frostbite often starts out with mild symptoms and can progress and become quite severe and even limb-threatening.
Mild frostbite is considered skin that is either red and painful, or white and numb. Severe frostbite includes blistering skin, hard skin (due to frozen bone and blood vessels), and possibly gangrene (tissue that has died and turned black, after blood vessels became frozen).
Frostbite is often associated with hypothermia (dangerously low body temperature).
Who’s At RiskFrostbite occurs most often to those exposed to extreme cold, so people who participate in cold-weather outdoor activities or live in or travel to cold climates are most at risk. Frostbite can also occur in those exposed to high winds, those with poor circulation, those in cramped positions who have tight-fitting clothing or boots, and those suffering from fatigue. Additionally, certain diseases and medications, alcohol consumption, and smoking increase risk for frostbite.
Signs & SymptomsFrostbite most often occurs on skin exposed to cold, such as on the face or ears, and on extremities, such as fingers and toes.
Skin that is mildly frostbitten may look either reddened or white. When frostbite becomes more severe, the skin may appear blistered and possibly blackened. In severe frostbite, the skin typically feels hard to the touch.
Self-Care GuidelinesIn the case of mild frostbite, the following measures should be taken:
- Move the person someplace that is warmer.
- Remove clothing from the affected area.
- Rewarm the affected area until sensation in the skin has returned and the skin is soft (for at least 30 minutes). Rewarming of frostbitten skin is typically accompanied by pain, swelling, and color change.
- To rewarm an extremity, place the limb in a bath of warm water (ie, 100°–105° F). Continue to circulate and refresh the warm water.
- To rewarm an area that cannot be soaked in a bath of water, apply a warm compress. (Ensure that the compress is warm but not hot.)
- Apply a clean (sterile, if possible), dry dressing to the affected area.
- Re-cover the affected area with dry clothing to keep it warm.
- Obtain medical help.
- Frostbitten areas, once thawed, should be moved as little as possible.
- Do not massage the affected area to attempt to rewarm it.
- Avoid disturbing any blisters or skin that has become gangrenous.
- Do not use direct heat (hair dryers, heating pads, etc) to rewarm the affected area.
- If there is potential for refreezing of an area, do not attempt to thaw, as thawing followed by refreezing can cause even more extensive damage to the area.
When to Seek Medical CareSeek medical care for any form of frostbite. For mild frostbite, perform the above self-care measures and then obtain medical help. For severe frostbite, call emergency medical services.
TreatmentsThe physician will first work to rewarm the affected area(s) while managing the pain associated with rewarming frostbitten skin. The area will be dressed and elevated to protect the sensitive skin from further damage.
In the case that the area becomes infected, an antibiotic will be given, and surgical management may be needed.
Follow-up care with a physician, physical therapist, and rehabilitation therapist is very important and may be long term.
Frostbite in Adult