What are the degrees of frostbite. How does frostbite occur. Who is at risk for frostbite. What are the symptoms of frostbite. How is frostbite treated. Can frostbite be prevented. What are the long-term effects of frostbite.

Understanding Frostbite: A Comprehensive Overview

Frostbite is a serious condition that occurs when skin and underlying tissues freeze due to exposure to extremely cold temperatures. This cold-induced tissue damage can have severe consequences if not treated promptly and properly. To fully grasp the complexities of frostbite, it’s essential to delve into its causes, risk factors, symptoms, and treatment options.

The Science Behind Frostbite: How Cold Damages Tissue

Frostbite develops when the skin and underlying tissues are exposed to temperatures below 0째C (32째F). As the temperature drops, several physiological changes occur:

• Vasoconstriction: Blood vessels narrow to conserve core body heat
• Reduced blood flow: Less warm blood reaches the extremities
• Ice crystal formation: Extracellular and intracellular ice crystals form, damaging cell membranes
• Cellular dehydration: Water moves out of cells, leading to electrolyte imbalances
• Microvascular injury: Endothelial cell damage causes localized edema
• Thrombosis: Microthrombi form due to hyperviscous blood flow and vasodilation

These factors collectively contribute to tissue ischemia and potential necrosis if left untreated. The severity of frostbite depends on the duration of exposure and the temperature, with lower temperatures and longer exposures resulting in more extensive damage.

Stages of Frostbite Development

Frostbite progresses through several stages as tissue damage worsens:

1. Frostnip: Mild, reversible skin irritation
2. Superficial frostbite: Skin becomes white or grayish-yellow, but underlying tissues remain soft
3. Deep frostbite: Skin and underlying tissues freeze, potentially leading to tissue death

Identifying Those at Risk: Vulnerable Populations and Risk Factors

While anyone exposed to extreme cold can develop frostbite, certain groups are particularly vulnerable:

• Homeless individuals
• Children and the elderly
• Outdoor enthusiasts and winter sports participants
• Military personnel
• People with certain medical conditions (e.g., diabetes, peripheral vascular disease)
• Individuals under the influence of alcohol or drugs

Risk factors that increase the likelihood of developing frostbite include:

• Inadequate clothing or shelter
• High wind chill factors
• Exposure to wet conditions
• High altitude
• Prolonged exposure to cold temperatures
• Impaired circulation
• Smoking
• Malnutrition
• Previous frostbite injury

Recognizing Frostbite: Signs and Symptoms to Watch For

Early recognition of frostbite symptoms is crucial for timely treatment and prevention of severe tissue damage. The signs and symptoms of frostbite vary depending on the stage and severity of the injury:

Early Symptoms (Frostnip)

• Skin redness
• Mild pain or discomfort
• Numbness or tingling sensation
• Skin that feels unusually firm or waxy

Advanced Symptoms (Superficial and Deep Frostbite)

• Skin discoloration (white, grayish-yellow, or bluish)
• Loss of sensation in affected areas
• Severe pain upon rewarming
• Blistering
• Swelling and inflammation
• Skin that feels hard or “wooden”

Is it possible to have frostbite without realizing it? Yes, in some cases, individuals may not immediately recognize frostbite symptoms due to the numbness caused by cold exposure. This underscores the importance of regular self-checks and awareness of environmental conditions when spending time in cold environments.

Treating Frostbite: From First Aid to Advanced Medical Care

The treatment of frostbite requires a multi-faceted approach, beginning with immediate first aid and potentially progressing to advanced medical interventions:

Immediate First Aid

1. Move to a warm, dry area
2. Remove wet or constrictive clothing
3. Gradually rewarm affected areas (avoid rubbing or using direct heat)
4. Immerse the affected area in warm (not hot) water (37-39째C or 98-102째F)
5. Protect thawed areas from refreezing

Medical Treatment

• Pain management
• Tetanus prophylaxis
• Thrombolytic therapy (in severe cases)
• Debridement of necrotic tissue
• Wound care and dressing changes
• Antibiotics (if infection develops)

How long does frostbite treatment typically take? The duration of treatment varies depending on the severity of the injury. Mild cases may resolve within days, while severe frostbite can require weeks or months of ongoing care and may result in permanent tissue damage or amputation.

Long-Term Consequences: Understanding the Aftermath of Frostbite

Frostbite can have lasting effects on affected individuals, even after initial treatment and recovery. Potential long-term consequences include:

• Increased cold sensitivity
• Chronic pain or numbness
• Changes in skin color or texture
• Reduced sensation or dexterity in affected areas
• Joint stiffness or arthritis
• Increased risk of future cold injuries
• Psychological impacts (e.g., anxiety about cold exposure)

Can frostbite cause permanent damage? Yes, severe cases of frostbite can lead to permanent tissue damage, including nerve damage, chronic pain, and in extreme cases, the need for amputation of affected digits or limbs.

Prevention Strategies: Safeguarding Against Frostbite

Preventing frostbite is far easier and more effective than treating it after the fact. Key prevention strategies include:

• Dressing appropriately for cold weather (layers, waterproof outer garments, insulated footwear)
• Protecting exposed skin (hats, gloves, face coverings)
• Limiting time spent outdoors in extreme cold
• Staying dry and changing out of wet clothing promptly
• Maintaining proper hydration and nutrition
• Avoiding alcohol consumption before or during cold exposure
• Being aware of wind chill factors and weather forecasts
• Using the buddy system when engaging in outdoor winter activities

How effective are chemical hand warmers in preventing frostbite? Chemical hand warmers can be a useful supplementary tool for maintaining warmth in cold environments, but they should not be relied upon as the sole method of frostbite prevention. Proper clothing and limiting exposure time remain the most effective preventive measures.

Frostbite in Special Populations: Unique Considerations

Certain groups require special attention when it comes to frostbite prevention and treatment:

Children

Children are particularly susceptible to frostbite due to their higher surface area-to-volume ratio and tendency to ignore discomfort while playing. Parents and caregivers should ensure children are properly dressed for cold weather and limit outdoor playtime in extreme conditions.

Elderly Individuals

Older adults may have reduced sensation in their extremities and impaired thermoregulation, making them more vulnerable to cold injuries. They should take extra precautions in cold weather and have their homes adequately heated.

People with Chronic Medical Conditions

Individuals with conditions such as diabetes, peripheral neuropathy, or cardiovascular disease may have reduced circulation or sensation in their extremities, increasing their frostbite risk. These individuals should work closely with their healthcare providers to manage their condition and take appropriate precautions in cold weather.

Outdoor Workers

Those who work outdoors in cold environments should be provided with appropriate cold-weather gear and trained in recognizing the early signs of frostbite. Employers should implement work-rest cycles and provide warm break areas to minimize cold exposure risks.

Advancements in Frostbite Treatment: Emerging Therapies and Research

The field of frostbite treatment continues to evolve, with researchers exploring new approaches to minimize tissue damage and improve outcomes:

• Hyperbaric oxygen therapy: May improve tissue oxygenation and reduce inflammation
• Tissue plasminogen activator (tPA): Thrombolytic therapy to improve blood flow in severe cases
• Iloprost: A prostacyclin analog that may improve microvascular blood flow
• Botulinum toxin: Potential use in managing chronic pain associated with frostbite
• Stem cell therapy: Exploring the potential for tissue regeneration in frostbite-damaged areas

What is the most promising new treatment for frostbite? While research is ongoing, thrombolytic therapy with tPA has shown significant promise in reducing amputation rates when administered within 24 hours of severe frostbite injury. However, this treatment is not without risks and is typically reserved for the most severe cases.

The Role of Climate Change in Frostbite Incidence

While it may seem counterintuitive, climate change can actually impact the incidence of frostbite in complex ways:

• Increased temperature variability: More frequent extreme weather events, including cold snaps
• Changes in winter recreation patterns: Altered snow patterns may lead to riskier behavior among winter sports enthusiasts
• Shifts in geographical risk: Areas previously unaccustomed to extreme cold may face new challenges in frostbite prevention and treatment

How might climate change affect frostbite rates in the future? Climate scientists predict that while average global temperatures are rising, some regions may experience more frequent and intense cold snaps due to changes in atmospheric circulation patterns. This could potentially lead to unexpected frostbite risks in areas not traditionally associated with extreme cold.

Frostbite in the Digital Age: Technology and Prevention

Modern technology offers new tools for frostbite prevention and early detection:

• Smartphone weather apps with real-time wind chill alerts
• Wearable devices that monitor skin temperature and provide warnings
• Advanced materials in cold-weather gear (e.g., phase-change materials, graphene-based fabrics)
• Telemedicine consultations for remote assessment of potential frostbite cases

Can smart clothing prevent frostbite? While smart clothing with integrated heating elements or temperature sensors can provide additional protection against cold, it should not be relied upon as the sole means of frostbite prevention. Traditional layering techniques and limiting cold exposure remain essential.

The Economic Impact of Frostbite: Healthcare Costs and Productivity Loss

Frostbite can have significant economic implications, both for individuals and society as a whole:

• Direct medical costs: Emergency treatment, hospitalization, long-term care
• Indirect costs: Lost productivity, disability payments
• Equipment and adaptation costs: Prosthetics, home modifications for severe cases
• Prevention costs: Investment in proper cold-weather gear and education programs

What is the average cost of treating a severe case of frostbite? While costs can vary widely depending on the severity of the injury and the required interventions, severe frostbite cases requiring hospitalization and potential amputation can cost tens of thousands of dollars in direct medical expenses alone.

Frostbite Awareness and Education: Key to Prevention

Improving public knowledge about frostbite is crucial for reducing its incidence and severity. Educational initiatives should focus on:

• Recognizing early signs and symptoms
• Understanding risk factors and vulnerable populations
• Proper cold-weather clothing and gear selection
• First aid techniques for suspected frostbite
• The importance of seeking prompt medical attention

How can communities improve frostbite awareness? Community-based programs, such as school presentations, public health campaigns, and outreach to vulnerable populations, can significantly enhance frostbite awareness and prevention efforts.

In conclusion, frostbite remains a significant health concern in cold climates and for those engaging in winter activities. By understanding its causes, recognizing its symptoms, and implementing effective prevention strategies, individuals can greatly reduce their risk of experiencing this potentially devastating cold injury. As research continues and technology advances, we can hope for even better outcomes for those affected by frostbite in the future.

Frostbite – StatPearls – NCBI Bookshelf

Continuing Education Activity

Frostbite, also known as freezing cold injury is tissue damage that occurs due to cold exposure, occurring at temperatures below zero degrees celsius. Homeless populations, children, and the elderly are especially vulnerable to frostbite. Prolonged duration and lower temperatures increase the risk of frostbite and the extent of the injury. Certain pre-existing conditions, including peripheral vascular disease, malnutrition, Raynaud’s disease, diabetes mellitus, and tobacco use may worsen frostbite-related tissue damage. This activity reviews the evaluation and treatment of frostbite and highlights the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the epidemiology of frostbite.

• Summarize how to evaluate a patient for frostbite.

• Review the treatment and management options available for frostbite.

• Explain interprofessional team strategies to improve care coordination and communication to advance treatment and prevention of frostbite, in turn leading to better patient outcomes.

Access free multiple choice questions on this topic.

Introduction

Frostbite, also known as freezing cold injury (FCI) is tissue damage as a result to cold exposure, occurring at temperatures below 0 degrees C. It is included in a spectrum of injury, from FCI to non-FCI and frostnip.[1] Any portion of exposed skin is prone to the damaging effects of frostbite. Patients are at high risk for ischemic tissue injury and necrosis. Patients that survive cold tissue injury are prone to secondary infection and dehydration from loss of the skin barrier. 

Frostbite tend to occur when the body is exposed to intense cold, resulting in vasoconstriction. The resulting decrease in blood flow fails to deliver heat to the tissues and eventually leads to ice crystal formation. Body parts most prone to frostbite include the feet, hand, ears, lips, and nose. Most cases of frostbite occur in the winter; homeless people and those who perform outdoors activity are most susceptible to the injury. The goal of treatment is to salvage as much tissue as possible so that maximal function remains.

Etiology

Skin exposure to freezing conditions causes frostbite. Prolonged duration and lower temperatures increase the likelihood and the extent of the injury. Certain pre-existing conditions may worsen tissue injury because of frostbite, including peripheral vascular disease, malnutrition, Raynaud’s disease, diabetes mellitus, tobacco use, etc. A unifying pattern among these conditions is poor impaired internal organ insulation or dysfunctional vasculature.

Risk factors for frostbite include:

• Winter season

• No or inadequate shelter from the cold

• High wind chill factor

• Exposure at a high altitude

• Prolonged duration of exposure

• Prolonged exposure to a wet condition

• Altered mental status

• Alcohol or drug abuse

• Malnutrition

• Immobilization

• Extremes of age

• Homeless

• Presence of medical disorders like diabetes, hypothyroidism, peripheral vascular disease, stroke or arthritis

• Smoker

Epidemiology

Classically, frostbite injuries were common in military personnel. However, with the increase in technology and accessibility, recreational sports have become a significant repository for frostbite cases. Homeless populations, children, and the elderly are especially vulnerable to frostbite. Risk factors include behavioral (lack of clothing, alcohol/drug consumption, access to shelter), physiological (dehydration, high altitudes, hypoxia), and other comorbidities with a predilection for tissue hypoxia (diabetes, peripheral vascular disease, Raynaud phenomenon).[1]

Pathophysiology

Frostbite has a prejudice for distal extremities, digits, and those portions of exposed skin with decreased perfusion (nose, ears) and less insulation. As the temperature of exposed skin drops, endothelial cell damage can cause localized edema in the extremity. Hyperviscous intravascular flow and vasodilation causes slowing forces, resulting in microthrombi. The constellation of microvascular injury, venous stasis, and microthrombi all contribute to the development of ischemia attributed to frostbite.  Depending on the extent of the exposure and subsequent cellular damage, injuries may be reversible or irreversible.

Normal skin blood flow is about 250 ml/min but during frostbite, the flow drops to less than 20-50 ml/min. As the temperature drops to below 0 degrees Centigrade, blood flow ceases. The slower venous system freezes before the arterial system.

Frostbite causes injury in the following ways:

• Direct damage of the cold to the tissues

• Indirect damage caused by dehydration

• Formation of ice crystals that leads to alteration in electrolytes and lipid layers

• Stasis of the microvessels leading to thrombus formation and ischemia

• Reperfusion injury

Recovery

Frostbite injury is classified into three zones which include:

1. Zone of coagulation which is the most distal and often the most severely injured. Here the injury is irreversible

2. Zone of stasis is the middle zone where the injury can be moderate to severe. but it reversible.

3. Zone of hyperemia is the proximal zone, which is the least injured.

In most cases, recovery from frostbite can take 5-30 days, depending on the severity of injury.

Histopathology

Initially, extracellular ice crystals form in exposed tissue. Continued cold exposure can cause intracellular ice crystals to form. Cell membrane damage results in electrolyte imbalances. As the transmembrane osmolarity gradient increases, cell membranes can rupture, resulting in cell death. Should tissue thawing occur, a reperfusion-associated inflammatory response through proinflammatory cytokines may cause additional tissue damage. Even more dangerous, additional cycles of thaw-refreeze can cause progressively worsening tissue ischemia and subsequent thrombosis.[2]

History and Physical

History of the patient should include duration and external temperatures during exposures.

Physical examination may reveal blanched, white skin. Patients may complain of heaviness in an exposed extremity as numbness progresses. In later stages of frostbite, exposed areas may become dark or purplish in hue due to poor vascular tone and pooling of blood. Superficial frostbite affecting the epidermis and subcutaneous fat will have pale, white blisters upon rewarming. Deep, full-thickness frostbite will become hemorrhagic with rewarming and may become gangrenous.[3] Injured skin may be well-demarcated with surrounding viable skin.

It is important to know that the initial exam will not accurately reveal the final depth and extent of the injury.

Rewarming injury

During rewarming, edema may start to appear within 3-5 hours and may last 7 days. Blisters tend to appear within 4-24 hours.

Presence of eschar will be obvious at 10-15 days and mummification with a line of demarcation may develop in 3-8 weeks.

Evaluation

Frostbite is a clinical diagnosis. Using additional laboratory testing may be helpful in determining the extent to which comorbid conditions may be contributing to tissue ischemia.  Technetium-99 (Tc-99) triple phase scanning and magnetic resonance angiography (MRA) may help to determine extent of amputation in the first few days after injury.[4][5] Tc-99 bone imaging may also assist in determining candidacy for tPA.[6]

Treatment / Management

Patients should have protection from further injury by covering exposed areas. The care of patients with frostbite begins with rewarming in the field if there is no anticipation of refreezing, as thaw-refreezing may worsen injuries.[3] Remove patients from the wind. Remove wet clothing and replace with dry clothing. Avoid vigorous rubbing as this can cause further damage.[7]

In-hospital management includes warm water baths, approximately 40-42 degrees C. Patients with systemic hypothermia should be managed by raising core temperature above 35 degrees C using warm IV fluids, and this should precede warming of the affected extremity.[7] This rewarming protocol also includes patients with other comorbidities or significant trauma. NSAIDS (ibuprofen) are indicated for controlling pain and preventing further inflammation, but stronger analgesics including narcotics may be necessary to achieve pain control. Frequent re-examination for sensation should accompany rewarming.

Although controversial, some sources recommend drainage or excision on white, cloudy-appearing blisters, while hemorrhagic blisters should be left intact. As with burn patients, particular care to prevent infections and dehydration should be a priority. Overly aggressive surgical debridement may remove skin that is otherwise viable, so complete rewarming should be achieved before surgical debridement. Signs of compartment syndrome (edema, pulselessness, extreme pain) should prompt urgent surgery. Delayed amputation (up to 6 weeks following injury) until the determination of tissue viability may prevent surgical morbidity from unnecessary procedures.[8][9]

Patients with full-thickness injuries and evidence of ischemia and no restoration of tissue perfusion after rewarming may be candidates for thrombolytic (tPA) therapy. [10] tPA may reduce the need for digital amputation.[11] Combination therapy with tPA and IV heparin may also reduce the need for digital amputation.[6] Iloprost, a potent vasodilator, has been used as a potential treatment to prevent ischemia in frostbite.[3] IV Iloprost is unavailable in the United States.

Differential Diagnosis

Careful assessment for systemic hypothermia and full-thickness tissue injury are essential in patients with apparent frostbite. Failure to correct for underlying comorbidities associated with frostbite (i.e., intoxication, cardiovascular compromise, significant environmental exposure, trauma) may cause systemic collapse and death. 

Staging

Traditionally, frostbite has a staging system similar to burns: 

• First degree – numbness, central pallor, surrounding erythema/edema, desquamation, dysesthesia

• Second degree – skin blistering with surrounding erythema/edema

• Third degree – tissue loss involving entire thickness of skin, hemorrhagic blisters

• Fourth degree – tissue loss involving deeper structures, resulting in loss of the affected part

Another classification based on frostbite on hands/feet has been proposed, which incorporate early imaging studies and may better predict outcomes. [12]

• Grade 1 – no cyanosis on the extremity; no risk of amputation or sequelae predicted

• Grade 2 – cyanosis on distal phalanx only; amputation to soft tissue and sequelae of fingernail/toenail sequelae predicted

• Grade 3 – cyanosis on intermediate and proximal phalanges; amputation to the bone of the digit and functional sequelae predicted 

• Grade 4 – cyanosis over carpal/tarsal bones; amputation to limb and functional sequelae predicted.

With this classification system, as grade increases, so does the likelihood of limb amputation.

Prognosis

Functional sequelae of frostbitten areas depend on the extent of tissue injury.[12] Unfavorable factors in frostbite include hemorrhagic blistering, non-blanching cyanosis, and firm skin after rewarming.[3] Patients should avoid cold exposure for up to a year after the initial injury.

Frostbite injury is associated with morbidity which is worse in the presence of the following:

• Presence of hemorrhagic blisters

• No edema

• Ongoing mottling

• Frank presence of frozen tissue

Complications of frostbite include:

Complications

Frostbite survivors may have an intolerance to cold in previously frostbitten areas, which may be a consequence of vasospasm and abnormal autonomic tone following cold injury. Complex regional pain syndrome is a common complication.[10] Autoamputation of an affected digit may precede surgical amputation. 

Deterrence and Patient Education

Risk modification including proper clothing, access to shelter, and maintaining hydration and nutrition are vital for protection against frostbite.[7] Patients should be advised to keep clothing as dry as possible and to wear multiple layers if they foresee cold exposure. Alcohol consumption should be discouraged. Emollients, although traditionally believed in Nordic countries to prevent frostbite, do not have protective effects in preventing frostbite and should be discouraged.[13]

Enhancing Healthcare Team Outcomes

Frostbite is a very common problem during winter and is associated with high morbidity. Because any part of the body can be affected, the condition is best managed by an interprofessional team that includes the emergency department physician, internist, wound care nurse, and a surgeon.

A multimodal approach to the treatment of patients with frostbite may provide the best chance for functional recovery.[1]

The key is patient education; frostbite in many instances can be prevented. Patients should be advised to dress well during winter, carry extra clothing supplies if they are into winter sports and avoid tight restrictive clothing. The nurse should advise against the use of alcohol, illicit drugs, and tobacco. For those with medical problems. it is important to ensure that their health is stable before venturing on an outdoors trip during winter.

Early consultation with the surgical services specializing in frostbite is crucial. During recovery from frostbite, as with other traumatic injuries with an expected loss of, function, consultation with rehabilitation services is vital, including wound care, physical therapy, occupational therapy, physical medicine & rehabilitation specialists, among others.

Finally, one should not immediately recommend amputation. The aim is to salvage all viable tissue. Thus, a wound care nurse should follow the patient and only debride infected superficial dead skin and let the damaged skin slough off on its own. Open communication with the interprofessional team is the key so that all patients receive the optimal standard of care.

Outcomes

The outcomes after frostbite injury are guarded and depend on the extent of the injury. Most people tend to have some residual deficits; either sensory or functional.

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Frostbite to fingers/hands. Contributed by Wikimedia Commons, Winky (CC by 2.0) https://creativecommons.org/licenses/by/2.0/deed.en

References

1.

Imray CH, Oakley EH. Cold still kills: cold-related illnesses in military practice freezing and non-freezing cold injury. J R Army Med Corps. 2005 Dec;151(4):218-22. [PubMed: 16548337]

2.

Rintamäki H. Predisposing factors and prevention of frostbite. Int J Circumpolar Health. 2000 Apr;59(2):114-21. [PubMed: 10998828]

3.

Roche-Nagle G, Murphy D, Collins A, Sheehan S. Frostbite: management options. Eur J Emerg Med. 2008 Jun;15(3):173-5. [PubMed: 18460961]

4.

Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. 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 Sep;25(5):969-78. [PubMed: 11040315]

5.

Barker JR, Haws MJ, Brown RE, Kucan JO, Moore WD. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg. 1997 Mar;38(3):275-9. [PubMed: 9088467]

6.

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 Dec;59(6):1350-4; discussion 1354-5. [PubMed: 16394908]

7.

Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, Cochran A, Imray CH. Frostbite: a practical approach to hospital management. Extrem Physiol Med. 2014;3:7. [PMC free article: PMC3994495] [PubMed: 24764516]

8.

Hallam MJ, Cubison T, Dheansa B, Imray C. Managing frostbite. BMJ. 2010 Nov 19;341:c5864. [PubMed: 21097571]

9.

Woo EK, Lee JW, Hur GY, Koh JH, Seo DK, Choi JK, Jang YC. Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience. Arch Plast Surg. 2013 Sep;40(5):510-6. [PMC free article: PMC3785582] [PubMed: 24086802]

10.

Sheridan RL, Goldstein MA, Stoddard FJ, Walker TG. Case records of the Massachusetts General Hospital. Case 41-2009. A 16-year-old boy with hypothermia and frostbite. N Engl J Med. 2009 Dec 31;361(27):2654-62. [PubMed: 20042758]

11.

Bruen KJ, Ballard JR, Morris SE, Cochran A, Edelman LS, Saffle JR. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007 Jun;142(6):546-51; discussion 551-3. [PubMed: 17576891]

12.

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 Winter;12(4):248-55. [PubMed: 11769921]

13.

Lehmuskallio E. Emollients in the prevention of frostbite. Int J Circumpolar Health. 2000 Apr;59(2):122-30. [PubMed: 10998829]

Disclosure: Hajira Basit declares no relevant financial relationships with ineligible companies.

Disclosure: Tanner Wallen declares no relevant financial relationships with ineligible companies.

Disclosure: Christopher Dudley declares no relevant financial relationships with ineligible companies.

Pictures, Symptoms, and Treatment of Each

Frostbite Stages: Pictures, Symptoms, and Treatment of Each

• Health Conditions
  • Featured
    • Breast Cancer
    • IBD
    • Migraine
    • Multiple Sclerosis (MS)
    • Rheumatoid Arthritis
    • Type 2 Diabetes
  • Articles
    • Acid Reflux
    • ADHD
    • Allergies
    • Alzheimer’s & Dementia
    • Bipolar Disorder
    • Cancer
    • Crohn’s Disease
    • Chronic Pain
    • Cold & Flu
    • COPD
    • Depression
    • Fibromyalgia
    • Heart Disease
    • High Cholesterol
    • HIV
    • Hypertension
    • IPF
    • Osteoarthritis
    • Psoriasis
    • Skin Disorders and Care
    • STDs
• Discover
  • Wellness Topics
    • Nutrition
    • Fitness
    • Skin Care
    • Sexual Health
    • Women’s Health
    • Mental Well-Being
    • Sleep
  • Product Reviews
    • Vitamins & Supplements
    • Sleep
    • Mental Health
    • Nutrition
    • At-Home Testing
    • CBD
    • Men’s Health
  • Original Series
    • Fresh Food Fast
    • Diagnosis Diaries
    • You’re Not Alone
    • Present Tense
  • Video Series
    • Youth in Focus
    • Healthy Harvest
    • No More Silence
    • Future of Health
• Plan
  • Health Challenges
    • Mindful Eating
    • Sugar Savvy
    • Move Your Body
    • Gut Health
    • Mood Foods
    • Align Your Spine
  • Find Care
    • Primary Care
    • Mental Health
    • OB-GYN
    • Dermatologists
    • Neurologists
    • Cardiologists
    • Orthopedists
  • Lifestyle Quizzes
    • Weight Management
    • Am I Depressed? A Quiz for Teens
    • Are You a Workaholic?
    • How Well Do You Sleep?
  • Tools & Resources
    • Health News
    • Find a Diet
    • Find Healthy Snacks
    • Drugs A-Z
    • Health A-Z
• Connect
  • • Breast Cancer
    • Inflammatory Bowel Disease
    • Psoriatic Arthritis
    • Migraine
    • Multiple Sclerosis
    • Psoriasis

Medically reviewed by Elaine K. Luo, M.D. — By Jill Seladi-Schulman, Ph.D. — Updated on June 23, 2018

What is frostbite?

Frostbite is a type of injury that can occur when your skin’s exposed to the cold. Cold exposure can cause the top layer of your skin and some of the tissues beneath it to freeze.

Frostbite is most common in your extremities, such as your fingers, toes, ears, and nose.

In many cases, your skin can recover from frostbite. However, in severe cases, tissue death or loss can occur.

Let’s take a look at the different stages of frostbite, their signs and symptoms, and how they’re treated.

Your skin is your largest organ and consists of several distinct layers. It protects you and also allows you to perceive sensations from your environment through your sense of touch.

Blood vessels can be found throughout your body, including in your skin. They work to carry blood to the various tissues of your body in order to keep them healthy.

When you’re in the cold, your blood vessels constrict, becoming narrower to divert the flow of blood away from extremities such as your fingers and toes. This helps to maintain your core body temperature. Over time, the lack of blood flow to these areas can cause damage to your skin and nearby tissues.

Your risk for frostbite increases if:

• you’re exposed to cold temperatures for long periods of time
• cold temperatures are accompanied by wind
• you’re at a higher altitude

Frostnip is the first stage of frostbite. It’s very mild and doesn’t damage your skin.

Share on Pinterest

When you have frostnip, your skin will turn red and feel cold to the touch. If you stay in the cold, it may begin to feel numb or have a prickling sensation.

Frostnip can be treated with simple first aid measures that include preventing further exposure to cold and rewarming.

Rewarming can be accomplished by soaking the affected area in warm (not hot) water for 15 to 30 minutes. Rewarming using heat sources such as stoves or heating pads should be avoided, as these can lead to burns.

As your skin begins to warm up, you may feel some pain or tingling. You can take an over-the-counter pain medication such as ibuprofen to ease any discomfort.

During this stage of frostbite, your skin will begin to turn from a reddish color to a paler color. In some cases, it may appear blue.

Share on Pinterest

Ice crystals may begin to form in your skin. As such, the affected area of your skin may have a hard or frozen feeling when you touch it.

Your skin may also begin to feel warm at this stage and you may observe some swelling. This is a sign that damage to your skin tissue is beginning to occur. The tissues below your skin are still intact, but prompt medical treatment is required to prevent further damage.

Rewarming should occur as soon as possible. Your doctor will give you pain medication to help with the pain that occurs with rewarming. After rewarming, they’ll wrap the injured area in order to protect it. Intravenous (IV) fluids may also be given to keep you hydrated.

Following rewarming, fluid-filled blisters may develop in the affected area. Your skin may appear to be blue or purple. You may also observe swelling and feel a burning or stinging sensation.

If you have blisters, your doctor may drain them. If any blisters appear infected, you’ll also be prescribed a course of antibiotics to treat the infection.

Many people can recover fully from superficial frostbite. New skin will form under any blisters or scabs. However, some people may have permanent problems that can include pain or numbness in the frostbitten area.

Deep frostbite is the most severe stage of frostbite and affects both your skin and the tissues that lie below.

Share on Pinterest

If you’re experiencing deep frostbite, the skin of the area may have a blue or splotchy look to it. It may feel numb to sensations such as cold or pain. Muscles close to the affected area may not work properly. Blood-filled blisters may also develop in people with deep frostbite.

Deep frostbite requires immediate medical attention. Like the treatment for superficial frostbite, your doctor will rewarm the area. They’ll give you pain medication, wrap the area, and may provide IV fluids.

If you have deep frostbite, you may also receive a type of medication called a “clot-buster.” Very severe cases of frostbite can lead to development of blood clots. This type of medication may help to improve blood flow to the injured area.

Following rewarming, the area will appear black and feel hard. This is due to tissue death in the affected area. Large blisters may also develop.

Your doctor may wait for several weeks after your frostbite injury in order to determine the full extent of the damage. In some cases, a procedure or surgery may be required to remove the dead tissue. For example, a toe that’s been severely damaged by deep frostbite may need to be amputated.

As with some cases of superficial frostbite, people that have had deep frostbite may have lasting problems that can include pain or numbness as well as increased sensitivity to cold in the frostbitten area.

Frostbite happens when your skin and underlying tissues are damaged through exposure to cold.

Frostbite has several stages. Some, such as frostnip, don’t cause permanent skin damage and can be treated with basic first aid. Others, such as superficial frostbite and deep frostbite, require prompt medical attention to avoid permanent damage.

Be sure to follow the tips below to prevent frostbite:

• Be aware of the weather forecast. Avoid spending extended periods of time in cold weather as well as coming into direct contact with metal surfaces or water while out in the cold.
• Dress appropriately for cold weather. Wear things like mittens or gloves, hats that cover your ears, scarves, sunglasses, or ski masks. Outer garments should be waterproof and windproof.
• Change out of wet clothes as soon as you can.
• Stay hydrated and eat nutritious meals. Avoid alcohol, as it can make you lose body heat more quickly.
• Be able to recognize the signs of frostbite. Remember that frostnip is a precursor to more serious frostbite. If you or someone else appears to be developing frostbite, seek warmth and medical attention as soon as possible.

Last medically reviewed on June 22, 2018

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• About skin: Your body’s largest organ. (n.d.).
  aad.org/public/kids/skin
• Frostbite. (2016).
  patient.info/health/frostbite-leaflet
• Frozen (the cold will bother you…). (2018).
  health.harvard.edu/blog/frozen-cold-frostbite-2018010313026
• Handford C, et al. (2014). Frostbite: A practical approach to hospital management. DOI:
  10.1186/2046-7648-3-7
• Mayo Clinic Staff. (2018). Frostbite.
  mayoclinic. org/diseases-conditions/frostbite/symptoms-causes/syc-20372656
• Ngan V. (2005). Frostbite.
  dermnetnz.org/topics/frostbite

Share this article

Medically reviewed by Elaine K. Luo, M.D. — By Jill Seladi-Schulman, Ph.D. — Updated on June 23, 2018

Read this next

• Hypothermia

  Medically reviewed by George Krucik, MD, MBA

  Hypothermia is a condition that occurs when your body temperature drops below 95°F. Major complications can result from this drop in temperature…

  READ MORE

• Frostnip

  Medically reviewed by Judith Marcin, M.D.

  Frostnip is the mild stage before frostbite begins. In this stage, the skin is still pliable and there’s no permanent tissue damage unless it…

  READ MORE

• Everything You Need to Know About Ice Burn

  An ice burn can develop when your skin is exposed to very cold temperatures. Learn how to prevent and treat it.

  READ MORE

• Diagnosing and Treating a Winter Rash

  Medically reviewed by Debra Sullivan, Ph. D., MSN, R.N., CNE, COI

  A winter rash is an area of irritated skin that develops during winter, often due to dry skin. Learn how to treat and prevent winter rashes.

  READ MORE

• What’s Causing My Swollen Fingertip and How Do I Treat It?

  Medically reviewed by William Morrison, M.D.

  There are numerous causes of fingertip swelling, and a few are potentially serious or life-threatening. Here’s when you should see a doctor and when…

  READ MORE

• Causes of Head and Skull Shape Abnormalities and How to Treat Them

  Medically reviewed by Karen Gill, M.D.

  While it’s common for the shape of people’s skulls to vary, a dent or irregularity in your skull can indicate a serious health condition. Learn about…

  READ MORE

• Whiplash Injury Overview

  Medically reviewed by Angela M. Bell, MD, FACP

  Whiplash occurs when a person’s head moves backward and then forward very suddenly with great force. This injury is most common following a car…

  READ MORE

• Everything You Need to Know About Rhabdomyolysis

  Rhabdomyolysis is a breakdown of muscle fibers that occurs due to muscle injury. Learn more about this condition.

  READ MORE

• Head Injury

  Medically reviewed by Seunggu Han, M.D.

  A head injury is an injury to your brain, skull, or scalp. This can range from a mild bump or bruise to a traumatic brain injury. Common head injuries…

  READ MORE

• Do You Have Heat Stroke or Heat Exhaustion? Learn the Signs

  Medically reviewed by Emelia Arquilla, DO

  Heat exhaustion occurs when the body loses excess water and salt. Heat stroke is a serious medical emergency. Learn more about the differences.

  READ MORE

Frostbite and hypothermia. Symptoms, first aid, prevention

Frostbite, or frostbite (lat. congelatio) – damage to body tissues under the influence of cold, often accompanied by general hypothermia of the body. A small memo will help to avoid the dangerous consequences of exposure to cold on the human body.

Frostbite especially often affects such parts of the body as auricles, nose, poorly protected limbs, especially fingers and toes. Most often, frostbite occurs in cold winters at ambient temperatures below minus 10-20 °C. However, it can be obtained by prolonged exposure outdoors at temperatures above zero, with high humidity and strong winds.
In addition, frostbite is promoted by tight and damp clothes and shoes, physical fatigue, hunger, prolonged immobility and uncomfortable position, cold injury, weakening of the body after illness, sweating of the legs, chronic diseases of the vessels of the lower extremities and the cardiovascular system, severe mechanical damage with blood loss, smoking, etc.

Frostbite degrees 9001 0

Frostbite I degree (mild) usually occurs with short exposure to cold. The affected area of ​​the skin is pale, reddened after warming, in some cases it has a purple-red tint; edema develops. The first signs of such frostbite are a burning sensation, tingling, followed by numbness of the affected area. Then there is skin itching and pain, which can be both minor and pronounced.
Skin necrosis does not occur. By the end of the week after frostbite, slight peeling of the skin is sometimes observed. Full recovery occurs by 5 – 7 days after frostbite.

II degree frostbite occurs with prolonged exposure to cold. In the initial period there is blanching, cooling, loss of sensitivity.
A characteristic feature is the formation of blisters filled with transparent contents in the first days after the injury. After warming, the pain is more intense and longer than with frostbite of the first degree, skin itching, burning are disturbing. Full restoration of the integrity of the skin occurs within 1 – 2 weeks, granulation and scarring are not formed.

With frostbite III degree the duration of the period of cold exposure and decrease in temperature in the tissues increases. The blisters formed in the initial period are filled with bloody contents, their bottom is blue-purple, insensitive.
The death of all skin elements occurs with the development of granulations and scars as a result of frostbite. Descended nails do not grow back or grow deformed. Rejection of dead tissues ends on the 2nd – 3rd week, after which scarring occurs, which lasts up to 1 month.

Frostbite IV degree occurs with prolonged exposure to cold, the decrease in temperature in tissues is the greatest. It is often combined with frostbite III and even II degree. All layers of soft tissues become dead, bones and joints are often affected.
The damaged area of ​​the limb is sharply cyanotic, sometimes with a marble color. Edema develops immediately after warming and increases rapidly. The temperature of the skin is much lower than that of the tissues surrounding the area of ​​frostbite. Blisters develop in less frostbitten areas where there is frostbite III – II degree. The absence of blisters with significantly developed edema, loss of sensitivity indicate frostbite of the IV degree.

Under conditions of prolonged exposure at low air temperature, not only local lesions are possible, but also general cooling of the body , which, in turn, can lead to loss of consciousness. Under the general cooling of the body should be understood as a condition that occurs when the body temperature drops below 34°C.
The onset of general cooling is facilitated by the same factors as with frostbite: high humidity, damp clothes, strong wind, physical overwork, mental trauma, past illnesses and injuries.

Symptoms of general cooling:
Mild degree : pale or moderately cyanotic skin, goosebumps, chills, difficulty speaking. The pulse is reduced to 60-66 per minute.

Moderate : characterized by severe drowsiness, depression of consciousness, a senseless look. The skin is pale, cyanotic, sometimes marbled, cold to the touch. Pulse – up to 50-60 per minute, weak filling. Breathing rare – up to 8-12 per minute, superficial.

Severe : Unconscious, convulsions, vomiting. The skin is pale, cyanotic, cold to the touch. The pulse is reduced to 36 per minute, weak filling. Breathing is rare, superficial – up to 3-4 per minute. There are severe and widespread frostbite up to glaciation.

First Aid

When giving first aid, remember not to:

• Rubbing damaged areas with snow. Not only will this worsen frostbite, but it can also lead to tissue damage and infection.
• Keep warm with dry heat, such as an open fire or a hot stove or radiator, as this warming increases the risk of irreversible damage.
• Give a large amount of alcohol or coffee, as with such a “hit” on the blood vessels, they may not withstand.
• Open blisters on frostbitten areas.

The first step is to place the victim in a warm place, take off his icy, wet clothes and call an ambulance. Before her arrival, the victim must be warmed. The best (though not always acceptable) way to warm a person is with your body. And better – two (top and bottom).

In case of frostbite of the 1st degree, the chilled areas should be warmed to redness with warm hands, light massage, rubbing with a woolen cloth, breathing, and then apply a cotton-gauze bandage.

In case of severe hypothermia, it is best to warm the victim in a warm bath (about 38 degrees, the water can be checked with your elbow, as when bathing a child), but do not immerse the victim entirely, but start from frostbitten places, warming in water for 20-30 minutes). In no case should you warm in a hot bath, as this can harm even more!

A heat-insulating bandage can be applied to the affected surface: a layer of gauze, a thick layer of cotton wool, another layer of gauze, and on top of oilcloth or rubberized cloth.

The affected limbs are fixed with the help of improvised means: a board, a piece of plywood, thick cardboard, applying and bandaging them over the bandage.

Also warm drink, hot liquid food (broth, cocoa, tea) will not hurt the victim.0009

• Do not drink alcohol – alcohol intoxication (like any other) actually causes a great loss of heat, while at the same time giving the illusion of warming. An additional factor is the inability to focus on the signs of frostbite.
• Do not smoke in the cold – smoking reduces peripheral blood circulation, and thus makes the limbs more vulnerable.
• Wear loose clothing. Wear multiple layers so that the air between them helps keep you warm. Do not go outside without mittens, hats, scarves.
• Watch your shoes. Tight shoes, lack of insoles, damp and dirty socks are often the main cause of frostbite. Warm insoles should be put in boots, and woolen ones should be worn instead of cotton socks.
• Do not wear metal jewelry (including gold, silver) in the cold – rings, earrings, etc. The metal cools much faster than the body, resulting in pain and cold injuries. In addition, the rings on the fingers impede the normal circulation of blood.
• Do not wet the skin – water conducts heat much better than air. Don’t go out into the cold with wet hair after a shower.
• Keep out of the wind – the chance of frostbite in the wind is much higher.
• Going for a walk in the cold, sometimes it is enough to have a hearty meal. It may also be useful to bring along a spare set of mittens, socks, and a thermos of hot tea.
• Remember, if you suddenly feel signs of hypothermia or frostbite in the cold, you should immediately go to the nearest warm room to warm up and inspect areas potentially vulnerable to frostbite. Try not to refrigerate re-damaged areas, as this can lead to more damage.
• After returning from the street, if you find an injured area, immediately consult a doctor. Left unattended, frostbite can lead to serious consequences, up to gangrene and loss of a limb.

Take care of yourself.

Frostbite, Reminders, Prevention

What is frostbite and its severity

Frostbite is the effect of low temperature on the human body, due to which the skin and underlying tissues are affected. This is a dangerous process that can lead to limb amputation. Such a cold injury should be treated as quickly as possible to prevent the development of irreparable complications.

Frostbite is divided into 4 degrees of severity depending on the depth of tissue damage. All types of injury differ in symptoms and treatments.

Frostbite classification:

• 1st degree is characterized by blanching of the skin area, and after warming – reddening of the affected area. In this stage of frostbite, only the upper layers of the skin are affected. The frostbitten area may tingle, hurt, or swell. Local hypothermia develops;
• The 2nd stage of frostbite includes all the symptoms of the 1st degree, but blisters are added to them, as with burns, with transparent contents. There are no scars in place of the blisters;
• 3rd degree is characterized by necrosis of the entire thickness of the skin. With frostbite of this severity, the blisters are filled with bloody contents. The victim needs urgent treatment in a hospital;
• 4th degree is the most severe. With it, the deepest damage to the skin and underlying tissues occurs. The first signs of deep frostbite – the damaged area becomes black. It has to be surgically removed, and a frostbitten leg or arm often needs to be amputated.

First aid for frostbite depends on the severity of the injury. First of all, it is necessary to determine the degree of frostbite in the patient in order to understand how to help him correctly.

How to understand that a person has frostbite and needs help

First aid for frostbite should be provided as early as possible to avoid the development of more serious conditions. In order for emergency care to arrive in a timely manner, you need to know what the first signs of frostbite look like. It is necessary to provide assistance to the victim in such cases:

• the patient complains of severe pain in the limbs, knees or other affected parts of the body;
• the skin on the affected areas has a marble tint, there is a feeling of tingling and burning in the frostbite;
• the victim has a severely low body temperature;
• limbs may swell on cooling;
• blisters appear on the skin with clear or bloody contents;
• with severe freezing, the victim is disoriented in space or is unconscious on the street.

Doctor’s advice. If you notice a person with such symptoms on the street in frosty weather, immediately call an ambulance and try to provide first aid to the victim before the arrival of specialists. And they must be taken into account, otherwise you can seriously harm the victim. The provision of first aid (PMP) for hypothermia and frostbite begins with the fact that the patient, as soon as possible, is transferred to a warm, safe place. Then you need to call an ambulance and try to alleviate the condition of the victim as much as possible. Properly rendered first aid for burns and frostbite can prevent the development of complications.

The algorithm of actions when providing first aid is as follows:

• take the patient to a warm place, remove all wet, cold clothes and shoes from him;

Cover

• with a blanket and drink a warm drink. Give the patient tea or milk, but coffee or alcohol is not allowed;
• Examine the affected areas and determine the severity of frostbite. With mild frostbite, you can do a gentle massage of the damaged areas of the skin, but only if there are no blisters;
• Apply a clean bandage to damaged areas with blisters and wait for the arrival of doctors;
• help with burns, frostbite of the 3rd-4th degree is more complicated. The patient needs to be given an anesthetic, calm, apply a sterile bandage to the affected area.

The right treatment for frostbite can save a person’s life. It is important to follow not only the procedure, but also the rules for providing assistance with hypothermia.

First aid rules for frostbite and hypothermia:

• the person providing first aid must do everything carefully and quickly so as not to harm the patient;
• should not be done with frostbite rubbing with alcohol tinctures, oils or other solutions;
• you can not open the bubbles yourself;
• should not be used for heating with a battery, hot bath, heating pad or open flame.

First aid is an important step in the treatment of frostbite of different stages. The above memo can be useful to everyone. By following the correct sequence of actions, you can alleviate the condition of the victim. But it should be remembered that careless and illiterate actions can harm the victim. Help with frostbite should be quick and correct.

In what situations is it necessary to urgently call an ambulance? But there are situations when it is necessary. It is necessary to involve specialists immediately in the following situations:

• severe condition of the victim: lack of consciousness or disorientation;
• if frostbite of limbs and other parts of the body has occurred due to winter injuries in the mountains;
• frostbite 3rd-4th degree of severity;
• severe hypothermia, body temperature does not return to normal for a long time;
• lack of sensation in the affected area;
• severe pain;
• large affected area.

In such situations, you need to call an ambulance as soon as possible so that doctors can provide high-quality specialized care to the patient.

Is it possible to rely on folk remedies for frostbite

People often turn to traditional medicine for help if there are no suitable medicines at hand. But not everyone knows in which situations such methods of treatment are beneficial, and in which they are harmful. Folk methods of treatment can only cure mild degrees of injury.

Calendula, chamomile or aloe compresses are effective as first aid for frostbite. They relieve inflammation and stimulate the healing of affected skin areas. But it is impossible to cure frostbite with traditional medicine alone, especially if the damage is serious. At 3-4 degrees, inpatient treatment is necessary, since there is a high risk of infection of the wound or an increase in the area of ​​​​the lesion.

Methods of treatment are chosen depending on the severity of frostbite. If there is an opportunity to consult a doctor, it is better to do it right away.

Prevention of frostbite

Prevention is always better and easier than cure. To protect yourself and your family from frostbite, it is enough to follow simple precautions when going outside in frosty weather. Preventive measures are as follows:

• for children and adults, you need to choose the right outerwear and shoes. Things should be made of dense materials, and it is recommended to choose shoes with a sole of at least a centimeter;
• dress in such a way that there are as few open areas of the body as possible so that the skin is less supercooled;
• do not go out hungry and tired, do not let a weak child go out alone;
• do not wear metal jewelry outside, do not give your child metal toys in winter. Pick up things that exclude contact of the naked body with metallic things or elements.

By following these simple rules, you can save your health.