• Results from the freezing of tissue
  • It is a disease of morbidity, not mortality
  • Risk correlated with temperature and wind speed
    • Risk is <5% when ambient temperature (includes wind chill) is > –15°C (5°F)
    • Most often occurs at ambient temperature < –20°C (–4°F)
  • Can develop within 2-3sec when metal surfaces that are at or below –15°C (5°F) are touched
  • Most commonly affects distal part of extremities, face, nose, and ears
  • High-risk groups: outdoor workers, elderly, homeless, drug or alcohol abusers, psychiatric disease


  • Freezing alone is usually not sufficient to cause tissue death
    • Thawing contributes markedly to the degree of injury
    • Endothelial damage, beginning at the point of thaw, is the critical event in frostbite
      • Resulting damage results in swelling, platelet aggregation, vessel thrombosis

Zones of Injury

  1. Zone of Coagulation
    • Most severe and usually most distal
    • Damage is irreversible
  2. Zone of Hyperemia
    • Least severe and usually most proximal
    • Generally recovers without treatment in <10d
  3. Zone of Stasis
    • Middle zone characterized by severe, but possibly reversible, cell damage
    • It is this zone for which treatment may have benefit

Clinical Features


Visual determination of tissue viability is difficult in first few weeks; classify early injuries as superficial or deep

Degree First (frostnip) Second Third Fourth
PathophysPartial-skin freezingFull-thickness skin freezingTissue loss involving entire thickness of skinExtension into subcutaneous tissues, muscle, bone, and tendon; little edema
SymptomsStinging and burning, followed by throbbingNumbness followed by aching and throbbingExtremity feels like a "block of wood" followed by burning, throbbing, shooting painsDeep, aching joint pain
CourseNumbness, erythema, swelling, dysesthesia, desquamation (days later)

Substantial edema over 4-6 hours; skin blisters form within 6-24 hours; Desquamate and form hard black eschars over several days

Hemorrhagic blisters form and are associated with skin necrosis and blue-gray discolorationSkin is mottled with nonblanching cyanosis and formation of deep, dry, black eschar
Pain with rewarmingMinimalMild to moderateSevereNone
PrognosisExcellentGoodOften poorExtremely poor

Differential Diagnosis

Cold injuries


  • Usually clinical


  • If hypothermia present, must rewarm to a core temperature of at least 35°C before treating frostbite[1]
  • Thawing
    • Do NOT attempt until the risk of refreezing is eliminated
      • Refreezing will cause even more severe damage
    • Rapid rewarming is the core of therapy and should be initiated as soon as possible
      • Extremities
        • Place in water with temperature of 37 to 39°C (98.6 to 102.2°F)
        • Approximately 20-30min, until extremity is pliable and erythematous
        • OR consider 38-40°C in whirlpool bath with antibacterial soap[2]
      • Face
        • Apply moistened compresses soaked in warm water
  • Analgesia
    • Rewarming is very painful
    • Provide parenteral opioids
  • Local wound care
    • Apply topical aloe vera cream q6hr (interrupts arachidonic acid cascade)
    • Affected digits should be separated with cotton and wrapped with sterile, dry gauze
    • Elevate involved extremities
    • Blister removal is controversial
      • Consider drainage of nonhemorrhagic bullae that interfere with movement
      • Never debride hemorrhagic bullae
  • Systemic care
    • Ibuprofen may be helpful in interrupting arachidonic cascade
    • Heparin and hyperbaric oxygen of little value
    • IV tPA reduces digit amputation rate
  • Tetanus
    • Reported complication of frostbite; provide prophylaxis
  • Antibiotics
    • Controversial
    • Penicillin G 500,000 units IV Q6 hours for 48-72 hours
    • Topical bacitracin may be as good or better than IV penicillin
    • Silver sulfadiazine cream not consistently beneficial
      • May interact with aloe vera cream
  • Surgery
    • May be required if wet gangrene or infection occurs
    • Usually not performed until full demarcation occurs (3-4wk)


  • Patients with superficial local frostbite may be discharged home if social circumstances allow


  • Up to 65% of patients with frostbite experience sequelae from their injuries
    • Hypersensitivity to cold, pain, ongoing numbness
    • Arthritis, bone deformities, scars, and skin and nail dystrophia

See Also




  1. Handford C, Thomas O, Imray CHE. Frostbite. Emerg Med Clin N Am. 2017;35(2):281–299.
  2. Crawford-Mechem C et al. Frostbite Treatment & Management. Aug 25, 2015.
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