- Ken Zafren, MD, FAAEM, FACEP, FAWM
Ken Zafren, MD, FAAEM, FACEP, FAWM
- Clinical Professor of Emergency Medicine
- Stanford University Medical Center
- Emergency Programs Medical Director, State of Alaska
- C Crawford Mechem, MD, FACEP
C Crawford Mechem, MD, FACEP
- Professor of Emergency Medicine
- Perelman School of Medicine, University of Pennsylvania
- Section Editor
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Frostbite results from the freezing of tissue. It is a disease of morbidity, not mortality. It is most frequently encountered in mountaineers and other cold weather enthusiasts, soldiers, those who work in the cold, the homeless, and individuals stranded outdoors in the winter [1-4]. Among patients with severe frostbite, timely diagnosis and treatment is essential to maximize tissue salvage.
This topic review will discuss the classification, presentation, diagnosis, and management of frostbite. Severe hypothermia, high altitude illness, and other related illnesses are discussed separately. (See "Accidental hypothermia in adults" and "High altitude illness: Physiology, risk factors, and general prevention" and "Acute mountain sickness and high altitude cerebral edema" and "High altitude pulmonary edema" and "High altitude disease: Unique pediatric considerations".)
Frostbite is a severe, localized cold-induced injury due to freezing of tissue. Immersion foot (also referred to as trench foot) is a nonfreezing cold injury (NFCI) that may also cause tissue loss and long-term sequelae. Milder forms of injury include frostnip and pernio:
●Frostnip refers to cold-induced, localized paresthesias that resolve with rewarming. There is no permanent tissue damage.
●Pernio, or chilblains, is characterized by localized inflammatory lesions that can result from acute or repetitive exposure to damp cold above the freezing point. Lesions are edematous, often reddish or purple, and may be very painful or pruritic (picture 1). Pernio is most common in young women, but both sexes and all age ranges may be affected . Permanent damage from pernio is uncommon, with symptoms and signs generally resolving within two to three weeks.
- Kroeger K, Janssen S, Niebel W. Frostbite in a mountaineer. Vasa 2004; 33:173.
- Küpper T, Steffgen J, Jansing P. Cold exposure during helicopter rescue operations in the Western Alps. Ann Occup Hyg 2003; 47:7.
- Petrone P, Kuncir EJ, Asensio JA. Surgical management and strategies in the treatment of hypothermia and cold injury. Emerg Med Clin North Am 2003; 21:1165.
- Cattermole TJ. The epidemiology of cold injury in Antarctica. Aviat Space Environ Med 1999; 70:135.
- Simon TD, Soep JB, Hollister JR. Pernio in pediatrics. Pediatrics 2005; 116:e472.
- Atenstaedt RL. Trench foot: the medical response in the first World War 1914-18. Wilderness Environ Med 2006; 17:282.
- Long WB 3rd, Edlich RF, Winters KL, Britt LD. Cold injuries. J Long Term Eff Med Implants 2005; 15:67.
- Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. J Trauma 2000; 48:171.
- Bhatnagar A, Sarker BB, Sawroop K, et al. Diagnosis, characterisation and evaluation of treatment response of frostbite using pertechnetate scintigraphy: a prospective study. Eur J Nucl Med Mol Imaging 2002; 29:170.
- Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med 2001; 12:248.
- Cauchy E, Davis CB, Pasquier M, et al. A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness Environ Med 2016; 27:92.
- Mills W. Clinical aspects of freezing cold injuries. In: Medical Aspects of Harsh Environments, Pandolf K, Burr R. (Eds), Office of the Surgeon General, Falls Church 2001. p.429.
- Grace TG. Cold exposure injuries and the winter athlete. Clin Orthop Relat Res 1987; :55.
- Nygaard RM, Whitley AB, Fey RM, Wagner AL. The Hennepin Score: Quantification of Frostbite Management Efficacy. J Burn Care Res 2016; 37:e317.
- Geng Q, Holmér I, Hartog DE, et al. Temperature limit values for touching cold surfaces with the fingertip. Ann Occup Hyg 2006; 50:851.
- Rintamäki H. Predisposing factors and prevention of frostbite. Int J Circumpolar Health 2000; 59:114.
- Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc 2006; 38:2012.
- Hashmi MA, Rashid M, Haleem A, et al. Frostbite: epidemiology at high altitude in the Karakoram mountains. Ann R Coll Surg Engl 1998; 80:91.
- Moore GW, Semple JL. Freezing and frostbite on mount everest: new insights into wind chill and freezing times at extreme altitude. High Alt Med Biol 2011; 12:271.
- McIntosh SE, Opacic M, Freer L, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med 2014; 25:S43.
- ORR KD, FAINER DC. Cold injuries in Korea during winter of 1950-51. Medicine (Baltimore) 1952; 31:177.
- Ervasti O, Juopperi K, Kettunen P, et al. The occurrence of frostbite and its risk factors in young men. Int J Circumpolar Health 2004; 63:71.
- Olsen N. Diagnostic aspects of vibration-induced white finger. Int Arch Occup Environ Health 2002; 75:6.
- Nagarajan S. Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2010-June 2015. MSMR 2015; 22:7.
- Lehmuskallio E, Lindholm H, Koskenvuo K, et al. Frostbite of the face and ears: epidemiological study of risk factors in Finnish conscripts. BMJ 1995; 311:1661.
- Graham CA, Stevenson J. Frozen chips: an unusual cause of severe frostbite injury. Br J Sports Med 2000; 34:382.
- Kuspis DA, Krenzelok EP. Oral frostbite injury from intentional abuse of a fluorinated hydrocarbon. J Toxicol Clin Toxicol 1999; 37:873.
- Wegener EE, Barraza KR, Das SK. Severe frostbite caused by Freon gas. South Med J 1991; 84:1143.
- Kurbat RS, Pollack CV Jr. Facial injury and airway threat from inhalant abuse: a case report. J Emerg Med 1998; 16:167.
- Sever C, Kulahci Y, Uygur F, Sahin C. Frostbite injury of the foot from portable fire extinguisher. Dermatol Online J 2009; 15:10.
- Daanen HA, van der Struijs NR. Resistance Index of Frostbite as a predictor of cold injury in arctic operations. Aviat Space Environ Med 2005; 76:1119.
- Harirchi I, Arvin A, Vash JH, Zafarmand V. Frostbite: incidence and predisposing factors in mountaineers. Br J Sports Med 2005; 39:898.
- Winter Weather Frequently Asked Questions: What is Frostbite? Centers for Disease Control and Prevention. www.bt.cdc.gov/disasters/winter/faq.asp#frostbite (Accessed on September 20, 2007).
- Reamy BV. Frostbite: review and current concepts. J Am Board Fam Pract 1998; 11:34.
- Millet JD, Brown RK, Levi B, et al. Frostbite: Spectrum of Imaging Findings and Guidelines for Management. Radiographics 2016; 36:2154.
- Kahn JE, Lidove O, Laredo JD, Blétry O. Frostbite arthritis. Ann Rheum Dis 2005; 64:966.
- Bruen KJ, Ballard JR, Morris SE, et al. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg 2007; 142:546.
- Gonzaga T, Jenabzadeh K, Anderson CP, et al. Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite. J Burn Care Res 2016; 37:e323.
- Tavri S, Ganguli S, Bryan RG Jr, et al. Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury. J Vasc Interv Radiol 2016; 27:1228.
- Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma 2005; 59:1350.
- Cauchy E, Marsigny B, Allamel G, et al. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. J Hand Surg Am 2000; 25:969.
- Nygaard RM, Lacey AM, Lemere A, et al. Time Matters in Severe Frostbite: Assessment of Limb/Digit Salvage on the Individual Patient Level. J Burn Care Res 2017; 38:53.
- Aygit AC, Sarikaya A. Imaging of frostbite injury by technetium-99m-sestamibi scintigraphy: a case report. Foot Ankle Int 2002; 23:56.
- Kraft C, Millet JD, Agarwal S, et al. SPECT/CT in the Evaluation of Frostbite. J Burn Care Res 2017; 38:e227.
- Barker JR, Haws MJ, Brown RE, et al. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg 1997; 38:275.
- Biem J, Koehncke N, Classen D, Dosman J. Out of the cold: management of hypothermia and frostbite. CMAJ 2003; 168:305.
- Su CW, Lohman R, Gottlieb LJ. Frostbite of the upper extremity. Hand Clin 2000; 16:235.
- Hutchison RL. Frostbite of the hand. J Hand Surg Am 2014; 39:1863.
- Zafren K. Frostbite: prevention and initial management. High Alt Med Biol 2013; 14:9.
- McIntosh SE, Hamonko M, Freer L, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med 2011; 22:156.
- Saemi AM, Johnson JM, Morris CS. Treatment of bilateral hand frostbite using transcatheter arterial thrombolysis after papaverine infusion. Cardiovasc Intervent Radiol 2009; 32:1280.
- Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. N Engl J Med 2011; 364:189.
- Poole A, Gauthier J. Treatment of severe frostbite with iloprost in northern Canada. CMAJ 2016; 188:1255.
- Handford C, Buxton P, Russell K, et al. Frostbite: a practical approach to hospital management. Extrem Physiol Med 2014; 3:7.
- Imray C, Grieve A, Dhillon S, Caudwell Xtreme Everest Research Group. Cold damage to the extremities: frostbite and non-freezing cold injuries. Postgrad Med J 2009; 85:481.
- Britt LD, Dascombe WH, Rodriguez A. New horizons in management of hypothermia and frostbite injury. Surg Clin North Am 1991; 71:345.
- McCauley RL, Heggers JP, Robson MC. Frostbite. Methods to minimize tissue loss. Postgrad Med 1990; 88:67.
- Chan TY, Smedley FH. Tetanus complicating frostbite. Injury 1990; 21:245.
- Finderle Z, Cankar K. Delayed treatment of frostbite injury with hyperbaric oxygen therapy: a case report. Aviat Space Environ Med 2002; 73:392.
- von Heimburg D, Noah EM, Sieckmann UP, Pallua N. Hyperbaric oxygen treatment in deep frostbite of both hands in a boy. Burns 2001; 27:404.
- Kemper TC, de Jong VM, Anema HA, et al. Frostbite of both first digits of the foot treated with delayed hyperbaric oxygen:a case report and review of literature. Undersea Hyperb Med 2014; 41:65.
- Hayes DW Jr, Mandracchia VJ, Considine C, Webb GE. Pentoxifylline. Adjunctive therapy in the treatment of pedal frostbite. Clin Podiatr Med Surg 2000; 17:715.
- Purkayastha SS, Bhaumik G, Chauhan SK, et al. Immediate treatment of frostbite using rapid rewarming in tea decoction followed by combined therapy of pentoxifylline, aspirin & vitamin C. Indian J Med Res 2002; 116:29.
- Miller MB, Koltai PJ. Treatment of experimental frostbite with pentoxifylline and aloe vera cream. Arch Otolaryngol Head Neck Surg 1995; 121:678.
- Thomas JR, Oakley HN. Nonfreezing cold injury. In: Medical Aspects of Harsh Environments, Pandolf KB, Burr RE (Eds), Office of the Surgeon General, Falls Church 2001. p.467.
- Ervasti O, Hassi J, Rintamäki H, et al. Sequelae of moderate finger frostbite as assessed by subjective sensations, clinical signs, and thermophysiological responses. Int J Circumpolar Health 2000; 59:137.
- NWS Windchill Chart. www.weather.gov/om/windchill (Accessed on September 20, 2007).
- Lehmuskallio E. Emollients in the prevention of frostbite. Int J Circumpolar Health 2000; 59:122.
- Lehmuskallio E. Cold protecting ointments and frostbite. A questionnaire study of 830 conscripts in Finland. Acta Derm Venereol 1999; 79:67.
- Lehmuskallio E, Rintamäki H, Anttonen H. Thermal effects of emollients on facial skin in the cold. Acta Derm Venereol 2000; 80:203.
- RISK FACTORS
- CLINICAL MANIFESTATIONS
- IMAGING STUDIES
- Prehospital care
- Hospital-based management
- - Rewarming
- - Thrombolysis for severe injury presenting within 24 hours
- - Prostacyclin therapy for severe injury presenting within 48 hours
- - Wound care
- - Infection prophylaxis
- - Surgical consultation
- Unproven therapies: Hyperbaric oxygen, pentoxifylline, heparin without thrombolysis, and others
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS