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Frostbite

• Signs and Symptoms
• What Causes It?
• Who's Most At Risk?
• What to Expect at Your Provider's Office
• Treatment Options
• Prognosis/Possible Complications
• Following Up
• Supporting Research

Frostbite occurs when skin and other tissues are exposed to very cold temperatures. It can occur within minutes following exposure to extreme temperatures, or even in above-freezing temperatures if there is a strong wind (wind chill) or if the person is at high altitude or wet. Frostbite usually affects the hands, feet, nose, cheeks, and ears. Superficial frostbite injures the skin and tissues just beneath it, but usually does not permanently injure tissue. Deep frostbite, which also affects muscle, nerves, and blood vessels, may result in tissue death, a condition known as gangrene.

Signs and Symptoms

The following are signs and symptoms of frostbite:

• Pain or prickling progressing to numbness
• Pale, hard, and cold skin with waxy appearance
• Flushing due to blood rushing to area after it's rewarmed
• Burning sensation and swelling from collected fluid that may last for weeks
• Blisters
• Black scab-like crust, which may develop several weeks later

What Causes It?

When exposed to cold, the body tries to preserve heat. To do this, blood vessels near the skin's surface narrow, forcing more blood into the core to keep the heart and lungs warm. This helps prevent hypothermia, which results when the body's temperature falls below 93°F (34°C). However, it also prevents the extremities (such as hands and feet) from receiving enough blood, allowing them to become cold. At first, the blood vessels alternate between narrowing and widening, to keep the extremities as warm as possible. But under extremely cold conditions, the vessels stop widening. When skin temperature drops low enough, ice crystals can form around and within the cells, freezing tissue and possibly rupturing cells. Cells may also be damaged by the lack of circulation that occurs when the body directs blood flow away from the extremities.

Who's Most At Risk?

These factors increase the risk for frostbite:

• Intoxication with alcohol or other substances
• Very young or very old age
• Cardiovascular disease
• Peripheral vascular disease (narrowing of blood vessels in extremities)
• Taking beta-blockers
• Diabetes
• Exhaustion, hunger, malnutrition, or dehydration
• Winter sports, especially at high altitudes
• Outdoor work
• Windy and or wet weather
• Homelessness
• Severe injury
• Smoking

What to Expect at Your Provider's Office

You should seek emergency medical care to treat frostbite as soon as possible. Your health care provider will ask about your exposure to cold, including what the temperature was and how long you were exposed. Your health care provider will also examine your skin, looking for signs of superficial and deep injury. It may not be apparent how badly you are injured until the area rewarms. Blood tests and imaging studies, such as magnetic resonance imaging (MRI), may be needed to determine the severity of your injury as well as any complications, such as infection.

Treatment Options

Prevention

If you are going to be outside in cold temperatures, it's essential to prevent frostbite. Take these steps to keep warm:

• Wear several layers of warm clothing that allow you to move while providing protection from wind and water.
• Wear dry, warm gloves, socks, and insulated boots. Replace any wet clothes.
• Cover your head, preferably with earflaps in extreme conditions. Thirty percent of heat loss occurs through the head.
• Drink plenty of fluids and eat plenty of food during lengthy outings. Do not drink alcohol, smoke cigarettes, or drink caffeine.
• Watch for the development of white patches on the face and ears of your companions. These may signal frostbite.

Treatment Plan

Frostbite is a medical emergency, and it's important to get conventional medical care as soon as possible. Mild frostbite is treated by rewarming the affected area, washing it with an antiseptic, and applying a sterile dressing. If medical care is not available immediately, seek shelter and rewarm a mildly frostbitten area in warm water (101° to 104° F) or by repeatedly applying warm cloths to the area for 30 minutes. Never use hot water, fire, a heating pad, or other dry heat because these methods may burn the skin before the feeling returns. Remove any jewelry from the affected area before rewarming because the area may swell. Never rub or massage frozen body parts, and avoid walking on a frostbitten foot if possible (however, if you are far from help, it is better to walk on frozen feet than to thaw them out). Wrap the area in dry dressings, putting dressings between fingers and toes to keep them separated. If there is any danger of refreezing, it is best not to thaw the area out until you reach warm shelter. Thawing and refreezing can cause serious damage to tissue.

Deep frostbite is treated by rapid thawing (only if there is no danger of refreezing) in a warm water bath. The patient should be hospitalized and have the frostbitten area elevated. Medication can help control pain. Health care providers will take steps to prevent or treat any infection. Deep frostbite is often accompanied by hypothermia, a medical emergency that requires hospital care.

Drug Therapies

Your health care provider may prescribe drugs, such as narcotic analgesics to treat pain, nonsteroidal anti-inflammatory drugs (NSAIDs) to treat pain and inflammation, antibiotics to prevent or treat infection, or a tetanus shot to prevent tetanus.

Surgical Procedures

If frostbite has caused tissue death in any area, such as a hand or foot, amputation may be necessary. Usually this decision is not made for several months, when the extent of the damage is more evident. (At first, frostbite may look worse than it is because the skin may be more seriously affected than the underlying tissues.) If, however, the person has serious infection, wet gangrene, or pain that won't respond to treatment, surgery may be required sooner.

Complementary and Alternative Therapies

It is important to seek conventional care for frostbite as soon as possible to prevent serious tissue damage. While nutritional supplements may enhance conventional treatment, dressing warmly, drinking fluids, and eating plenty of food before and during exposure to cold remain the key to avoiding and treating frostbite because they help maintain the body's core temperature.

Nutrition and Supplements

• Vitamin C -- One well-designed animal study suggested that vitamin C may have some beneficial effect on frostbite when combined with standard medical treatment. However, no studies have been done in humans.
• Antioxidants -- When taken prior to cold exposure, antioxidants such as vitamin E, quercetin, and grape seed extract may help protect against development of frostbite or other cold-related injuries.

Herbs

Herbs may be used along with conventional medical treatment for frostbite, but should never be used to self-treat the condition.

• Cayenne pepper ( Capsicum spp. ) in topical form has long been used traditionally in China and Japan to treat frostbite.
• Poplar buds (Populus spp. including P. nigra, P. canadensis, and P. tacamahaca ), also known as balm of Gilead and balm of Mecca, may be used in mild cases of frostbite as an ointment or other topical formula (containing 20 - 30% bud exudate) to alleviate the pain and reduce the risk of infection associated with frostbite.
• Also used topically are calendula ( Calendula officinalis) , chamomile ( Matricaria recutita) , and horsetail (Equisetum arvense) .

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for frostbite based on his or her knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Agaricus -- primary remedy for the burning, itching, redness, and swelling associated with frostbite
• Apis mellifica -- for the burning or stinging sensation and redness associated with frostbite, particularly if there is excessive swelling. People who benefit from this remedy may also have a dull pain in the back of the head.
• Carbo vegetabilis -- for people who feel faint or who have difficulty breathing
• Lachesis -- for frostbite with a blue or purple discoloration. The skin may bleed easily, and irreversible tissue damage may result if it is not treated. This remedy is most appropriate for people who are restless and unsettled.
• Silicea -- for frostbite in thin, frail people who typically feel cold and tired. This remedy is most appropriate for those who have pus-filled wounds.

Massage

Frostbitten areas should never be massaged or vigorously rubbed.

Prognosis/Possible Complications

The outlook for frostbite depends on the depth of tissue injury and can range from complete recovery to amputation.

Possible complications of frostbite include the following:

• Increased sensitivity to cold
• Changed skin color
• Faulty nail growth in an affected hand or foot
• Profuse sweating
• Pain with use of the affected area
• Altered sensation in the affected area
• Arthritis
• Skin cancer

Following Up

Because the damage caused by frostbite is not always immediately evident, health care providers will monitor your condition over weeks or months to determine the severity of your injury.

Supporting Research

Barker JR, Haws MJ, Brown RE. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg . 1997;38(3):275-279.

Beers MH, Porter RS, et al. The Merck Manual of Diagnosis and Therapy . 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:2610-2611.

Bhaumik G, Srivastava KK, Selvamurthy W, Purkayastha SS. The role of free radicals in cold injuries. Int J Biometeorol. 1995;38(4):171-175.

Blumenthal M, Goldberg A, Brinckmann, J, eds. Herbal Medicine; Expanded Commission E Monographs. Boston, Mass: Integrative Medicine Communications; 2000:52-56, 311-313.

Carey CG, Schaiff RA. The Washington Manual of Medical Therapeutics . 29th ed. Philadelphia, Pa; 1998:498-499.

Danzel DF. Frostbite. In: Rosen P, et al., eds. Emergency Medicine: Concepts and Clinical Practice. Vol 1. 4th ed. St. Louis, Mo: Mosby; 1998:953-961.

Davies A. Nursing a patient with frostbite. Nurs Times. 2005 Nov 15-21;101(46):52-4.

Goldman L, Bennett JC. Cecil Textbook of Medicine . Vol 1. 21st ed. Philadelphia, Pa: W.B. Saunders Company; 2000:366.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 151.

Laskowski-Jones L. Responding to winter emergencies. Nursing. 2000;30(1):34-39.

Lehmuskallio E, Lindholm H, Koskenvuo K, Sarna S, Friberg O, Viljanen A. Frostbite of the face and ears: epidemiological study of risk factors in Finnish conscripts . BMJ. 1995;311(7021):1661-1663.

McAdams TR, Swenson DR, Miller RA. Frostbite: an orthopedic perspective. Am J Orthop . 1999;28(1):21-26.

Mills WJ Jr. Frostbite: experience with rapid rewarming and ultrasonic therapy. Part II. 1960. A laska Med . 1993;35(1):10-18.

Mills WJ Jr. Frostbite and hypothermia: current concepts. 1973. Alaska Med . 1993:35(1):28.

Mills WJ Jr. Frostbite: a discussion of the problem and a review of the Alaskan experience. 1973. Alaska Med . 1993;35(1):29-40.

Mills WJ Jr. Summary of treatment of the cold injured patient: frostbite. 1983. Alaska Med . 1993;35(1):61-66.

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Mills WJ Jr, Whaley R, Fish W. Frostbite: experience with rapid rewarming and ultrasonic therapy. Part III. 1961. Alaska Med . 1993;35(1):19-27.

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Pinzur MS, Weaver FM. Is urban frostbite a psychiatric disorder? Orthopedics. 1997;20(1):43-45.

Pulla RJ, Pickard LJ, Carnett TS. Frostbite: an overview with case presentations. J Foot Ankle Surg . 1994;33(1):53-63.

Purkayastha SS, Chhabra PC, Verma SS, Selvamurthy W. Experimental studies on the treatment of frostbite in rats. Indian J Med Res. 1993;98:178-184.

Raffle PAB, et al. Hunter's Disease of Occupations . 8th ed. London, England: Edward Arnold; 1994:310-311.

Reamy BV. Frostbite: review and current concepts. J Am Board Fam Pract. 1998;11(1):34-40.

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• Review Date: 11/18/2006
• Reviewed By: Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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