Depending upon the depth of tissue damage, frostbite has been classified into various categories, each of which has its own characteristic clinical manifestations. These include:

First-degree frostbite

Commonly known as “frost nip”. Involves only the superficial part of skin. Presents as:

• Itching
• Painful sensations like pins and needles followed by numbness
• Red or white patches on the skin

Second-degree frostbite

It is also called “superficial frost bite”. The skin freezes without the involvement of deeper soft tissues. It manifests as:

• Hardening of skin
• Blistering
• Yellowish, waxy appearance of skin
• Blackening of the skin
• Swelling
• Burning
• Edema
• Erythema

Third- and fourth-degree frostbite

All the layers of the skin are involved at this stage. Permanent and irreversible tissue damage occurs. Deeper tissues like muscles, tendons, nerves get involved at this point. If left untreated, gangrene might set in, which is a major indication for amputation of the affected organs. It presents as:

• Loss of sensations as a result of destruction of nerve endings
• Purplish blisters formation
• Formation of a black eschar after about 2 weeks

• Pain

  When warmed, the area becomes blotchy red, swollen, and painful. Blisters form within 4 to 6 hours, but the full extent of injury may not be apparent for several days. [merckmanuals.com]

  The process of rewarming is extremely painful; the tissues will not hurt at all until they are rewarmed, but once they begin to thaw, the pain is intense. [health.williams.edu]

  A pain specialist may be needed to advise about pain relief. Chilblains [ 3 ] Most idiopathic chilblains resolve spontaneously without treatment. Careful protection from further exposure should be advised. [patient.info]

  Thawing and reperfusion is often intensely painful. Residual tingling sensation starting after one week has been described and may be due to an ischaemic neuritis. Signs / Initial appearances are often deceptively benign. [theadventuremedic.com]

• Hypothermia

  ‘Winter weather can be nasty, and two of the meanest winter culprits are hypothermia and frostbite.’ ‘None from this group suffered from severe or very severe frostbite.’ Pronunciation [en.oxforddictionaries.com]

  Hypothermia and frostbite injuries occur in cold weather activities and sporting events. A PubMed search was used to identify original research and review articles related to cold, frostbite, and hypothermia. [ncbi.nlm.nih.gov]

  Hypothermia occurs when the body's core temperature drops below 95 degrees. [nsc.org]

  Hypothermia and concomitant injuries should be evaluated and systemic hypothermia should be corrected to a core temperature of 34°C. [theadventuremedic.com]

• Gangrene

  Freezing of deep tissue causes dry gangrene with a hard black carapace over healthy tissue. Wet gangrene, which is gray, edematous, and soft, is less common. [merckmanuals.com]

  Gangrene of the extremities in the neonatal period is rare. Etiology is not identified in most cases and management is usually conservative. [ncbi.nlm.nih.gov]

  A frostbitten tissue, if thawed and then subsequently frostbitten (in the near future), will turn gangrenous and be lost 100% of the time. [health.williams.edu]

  This is called dry gangrene. Wet gangrene, where the skin looks soft and grey, can also occur. Gangrenous skin will eventually fall away but, in some cases, surgery is required to remove it. [betterhealth.vic.gov.au]

• Chills

  Consider keeping them indoors whenever the temperature or the wind chill is reported to be -27°C (-16°F) or lower. At this temperature, exposed skin begins to freeze. [caringforkids.cps.ca]

  / the chill gray dawn / A chill wind / be chilled to the bone / catch a chill Chilling द्रुतशीतन, डरलाग्दो, I'm chilled to the bone Freeze जम्नु, स्थिर, फ्रीज, ख्वाउँकेगु, ख्वयेके, I would freeze to death in this office if the air condition is turned [studysite.org]

  Risk of frostbite varies according to the temperature felt, meaning the wind chill index. Weather forecasters use the term “wind chill index” to indicate the temperature felt on skin exposed to the cold. [quebec.ca]

  This is accomplished through the application of a meteorological dataset that has been demonstrated to characterize conditions in the region as inputs to new parameterizations of wind chill equivalent temperature (WCT) and facial frostbite time (FFT). [ncbi.nlm.nih.gov]

  Form : Noun How To Spell Frostbite : [frawst-bahyt, frost-] Synonyms For Frostbite, Similar to Frostbite Ague, Algidity, Algor, Chill, Chilliness, Coldness, Draft, Freeze, Frigidity, Frost, Gelidity, Glaciation, Iciness, Inclemency, Rawness, Refrigeration [urdupoint.com]

• Camping

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  If you are camping and unable to get indoors, leave the extremity frozen. Do NOT burn the injured area (which may lack feeling). Warming over a fire or next to a heater should be avoided! [medterms.com]

  Setting up camp Birdie Bowers and Teddy Evans take lunch in the tent © The British party arrived in Antarctica in January 1911 and set up camp on Ross Island in McMurdo Sound. [bbc.co.uk]

• Nausea

  Although parenteral narcotic agents are the usual method of pain relief, they have well-described adverse effects such as heavy sedation, respiratory depression, and nausea and vomiting. [ncbi.nlm.nih.gov]

  Signs and symptoms of mild hypothermia include: Shivering Dizziness Hunger Nausea Faster breathing Trouble speaking Slight confusion Lack of coordination Fatigue Increased heart rate Moderate to severe hypothermia As your body temperature drops, signs [abc7ny.com]

  Common side effects: In clinical studies, common adverse reactions due to inhaled iloprost included: vasodilation (flushing, 27%), cough (39%), headache (30%), flu syndrome (14%), nausea (13%), neck spasms (12%), hypotension (11%), insomnia (8%), and [en.wikipedia.org]

  Hypothermia symptoms include hunger, nausea, apathy, confusion, lethargy, slurred speech, loss of consciousness, and coma. [emedicinehealth.com]

• Foot Pain

  Pius II, a 15th century Pope, developed chronic foot pain following frostbite at age 30. Later in life he was progressively disabled by arthritis elsewhere and by colic, which may have been due to kidney stones. [ncbi.nlm.nih.gov]

  You stop outside of a room to listen to the ambulance report about a homeless patient who has been brought in for foot pain. He is intoxicated and was found asleep in a snow bank. [epmonthly.com]

• Blister

  Large, clear blisters are left intact or aspirated using sterile technique. Hemorrhagic blisters are left intact to avoid secondary desiccation of deep dermal layers. Broken vesicles are debrided. [merckmanuals.com]

  Post-Thaw Care / Blisters containing clear or milky fluid should be debrided and covered in aloe vera, a potent antiprostglandin agent 6 hourly. [theadventuremedic.com]

  Severe frostbite If the fluid inside blisters is clear, then a full recovery is likely. However blood-filled blisters signal damage to the deeper tissues. Typically, the affected skin becomes hard and black. This is called dry gangrene. [betterhealth.vic.gov.au]

  They can appear as various types of ulcers and blisters.[7] Bullous pemphigoid is a condition that causes itchy blisters over the body that can mimic frostbite.[11] It does not require exposure to cold to develop. [en.wikipedia.org]

• Erythema

  These are associated erythema and edema. Third degree (deep) – This involves hemorrhagic (blood-filled) blisters, indicating that the injury has extended deeper into the dermis. [awls.org]

  On examination, two distinct areas of significant frostbite in the left flank with surrounding erythema were revealed. [ncbi.nlm.nih.gov]

  First-degree frostbite has the following characteristics: Nonsensate, central, white plaque surrounded by a ring of hyperemia Epidermal involvement Mild edema Sequelae over the next few weeks include desquamation, transient swelling and erythema, and [emedicine.medscape.com]

  (atrial and ventricular fibrillation) decreased respiratory rate CO2 retention leads to hypoxia/respiratory acidosis disorientation, comatose frostbite (similar to burns) traditional classification 1st degree – central whitish area with surrounding erythema [orthobullets.com]

• Pruritus

  Associated conditions frostnip mildest cold exposure injury only affects superficial layers of skin (blanching, numbness) but no dermis damage reversible chilblain (pernio) occurs in cold, nonfreezing temperatures in dry conditions burning sensation, with pruritus [orthobullets.com]

• Dry Skin

  Stage 3: Hyperaemic phase This can last between 2 weeks to 3 months and the limb becomes hot red with dry skin, the limb becomes painful and has a degree of paraesthesia, in severe cases blistering and demarcation of the skin may occur. [doi.org]

• Tingling

  If the skin isn’t protected or warmed, it will start to feel like it’s tingling and will look grey. If the skin freezes, the area will have no feeling and will be shiny and white. Frostbite can happen in cold wind, rain, or snow. [caringforkids.cps.ca]

  The symptoms of frostnip include: Skin that looks red Skin that tingles or feels numb The symptoms of frostbite include: Skin that is red and then becomes white or grayish-yellow Skin that burns, tingles, or is numb Skin that feels hard and swollen Blisters [urmc.rochester.edu]

  Tingling and numbness are signs to go indoors. [seattlechildrens.org]

  If the area turns pink or if the child begins to feel tingling, you may stop the re-warming and have your child seen by a doctor as soon as possible. Prevention Dress your child warmly with layers of dry clothes. [nationwidechildrens.org]

  First a person’s skin is cold and red, a prickly or tingling feeling, burning, then numbness. Skin grows hard, pale and waxy, Lindberg said. Joints and muscles get stiff and clumsy. [denverpost.com]

• Paresthesia

  Milder forms of injury include frostnip and pernio: ● Frostnip refers to cold-induced, localized paresthesias that resolve with rewarming. [web.archive.org]

  The skin will be pale and may have paresthesias or numbness. It is common on exposed skin including the cheeks, ears, and nose. The skin is still pliable. This is a major difference between frostnip and frostbite. [awls.org]

  Sequelae include paresthesias, hyperhidrosis, and persistent or transient cold sensitivity. [emedicine.medscape.com]

  […] cold sensitivity, persistent color changes, hyperhidrosis) treatment calcium channel blockers, vasodilators, beta blockers, surgical sympathetectomy indications late, persistent vasospastic disease neuropathy (cold/heat hypersensitivity, hypesthesia, paresthesia [orthobullets.com]

• Tremor

  Possible long-term sequelae of cold injury include: Chronic pain Paraesthesiae and sensory deficits, tremor. Hyperhidrosis or anhidrosis. Cracking of skin and loss of nails. Permanent discolouration and/or scarring. Vasospasm, cold sensitivity. [patient.info]

  […] include the following: Cold sensitivity Paresthesias and sensory deficits Peeling or cracking skin Loss of fingernails or toenails Hyperhidrosis or anhidrosis Muscle atrophy Premature closure of epiphyses Decreased mineralization of bone Joint stiffness Tremor [emedicine.medscape.com]

  Presence of hemorrhagic blisters No edema Ongoing mottling Frank presence of frozen tissue Complications of frostbite include: Paresthesias Loss of nails Anhidrosis of hyperhidrosis Cracked skin Atrophy of muscles Chronic pain Joint stiffness Phantom pain Tremor [ncbi.nlm.nih.gov]

• Excitement

  Liquid Nitrogen Liquid nitrogen not exciting enough for you? How about adding liquid oxygen to the mix! Static Electricity Experiments We hope you'll get a charge out of these shocking experiments! [education.jlab.org]

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• Insomnia

  Common side effects: In clinical studies, common adverse reactions due to inhaled iloprost included: vasodilation (flushing, 27%), cough (39%), headache (30%), flu syndrome (14%), nausea (13%), neck spasms (12%), hypotension (11%), insomnia (8%), and [en.wikipedia.org]

The diagnosis of frostbite is made with through the following elements [4].

• Physical examination
• Tissue biopsy
• Complete blood count (CBC)
• Blood urea nitrogen (BUN)
• Blood electrolytes
• Serum creatinine levels
• Blood glucose levels
• Liver function tests (LFTs)
• Urinalysis
• Gram staining of cultures obtained from the tissues
• Radiography
• Angiography
• Technetium-99m (99m Tc) scintigraphy
• Bone scans
• Laser Doppler flowmetry
• Magnetic resonance imaging

The management of frostbite consists of the following [5].

Field care

• Immediate removal of the patient from the cold environment.
• Removal of wet, soaked clothing.
• Airway, breathing and circulation of the patient must be checked.
• Thawing for about 20 to 40 minutes for superficial frost bite and for almost an hour in case of deep tissue involvement [6].
• Splinting or wrapping of the affected part to avoid movements and damage caused by ice crystals
• Heating and rewarming by using circulating water at 40° to 42° C. Rewarming may be passive or active.

Medical treatment

• Analgesics such as non-steroidal antiinflammatory drugs (NSAIDs) are administered to treat the pain of rewarming and to reduce inflammation.
• Intra-venous alpha blockers (eg. reserpine) can be given for pain relief and edema formation
• Tetanus toxoid is given as prophylaxis to prevent infection with Clostridium tetani.
• Antibiotics are given to prevent secondary infections.
• Low molecular weight heparin is given to prevent venous thrombosis [7].
• Vasodilators may also be given to improve peripheral blood flow.
• Thrombolytic agents such as streptokinase are used to reduce the risk of the formation of thrombi.

Surgical interventions

• Excision of the areas affected by wet gangrene should be done.
• Surgical amputation of the parts affected by necrosis and gangrene is essential. However, prompt amputation is not recommended.
• Needle aspiration of blisters can also be done.
• Escharotomy may be needed to lessen the pull of the affected part on the surrounding tissues.
• Routine hydrotherapy for 30 to 45 min at 40° C is done as a rehabilitative measure.
• Skin grafting may be needed.

Long-term therapy

• Physiotherapy is recommended to enable proper use of the affected limb.
• Psychotherapy is recommended for the patients who undergo amputation of the limb.
• Cosmetic reconstruction of nose, ears, toes that have been amputated may also be done according to the patients’ demands.

Irreversible tissue damage is common after frostbite. The mortality rate related with frost bite is about 11%.

Inadequate blood supply to the extremities when exposed to hypothermic environmental conditions as a result of vasoconstriction leading to inadequate tissue perfusion is the basic cause of frostbite.

Various risk factors associated with frostbite are:

• Smoking
• Alcohol use
• Use of certain drugs like beta blockers
• Diabetes mellitus
• Peripheral neuropathy

Frostbite is common at the altitudes of 11,000-22,000 feet above sea level. It is common in military personnel, mountaineers and in people who engage in activities like high altitude camping. Any racial, gender or age association has not been established as yet.

Body responds to hypothermia by directing the flow of blood from extremities towards the core organs like heart and lungs in an effort to maintain body’s homeostasis. This is done by peripheral vasoconstriction. The body parts likely to be exposed are affected the worst. These include earlobes, tip of nose, chin, fingers, knuckles and toes. Decrease in the flow of blood in the peripheral parts decreases the already falling temperature even further.

If exposure to the cold continues, cellular changes start taking place. Ice crystal formation occurs around the cell membrane [2]. Dehydration of cells causes them to shrink and they begin to die as a result of loss of cellular architecture [3]. Capillary endothelium is also affected which causes leakage of blood out of the blood vessels into the tissue spaces. Blood also begins to clot inside the small vessels, initiating the recruitment of the mediators of inflammation which cause further tissue damage.

Frostbite can be prevented by the following measures [8] [9] [10].

• The affected part of the body should not be excessively moved as the ice crystals that have formed around the cells can cause further damage.
• The affected part should not be rubbed or massaged for the purpose of warming.
• Education of soldiers who are more susceptible to frostbite.
• While going to high altitudes, appropriate warm clothing must be chosen.
• Clothing should be protected from getting wet.
• Position should be changed every few minutes or so in extremely cold conditions to maintain the circulation.
• Skin should be examined every 20 minutes or so for signs of frost bite.
• Smoking and drinking for the purpose of keeping warm should be avoided in cold weather as it slows the circulation and aggravates the condition.

Frostbite refers to the damage to the tissues caused by prolonged exposure to cold environment [1]. Exposure to minus 10 °C for even a few minutes is enough to cause frostbite. The parts of the body that are normally exposed to the external environment are likely to be affected the most.

The condition goes unnoticed at first as numbness sets in almost immediately. A form of frostbite, the “trench foot”, is common in soldiers. It is however, a preventable condition that can be avoided with proper precautionary measures.

Freezing of the body tissues when exposed to cold environmental conditions for prolonged time period is known as frost bite. It commonly occurs in hands, feet, toes, earlobes and tip of nose.

Initially, it is limited to the superficial layer of skin only but later on, it proceeds to deeper tissues. Tingling is followed by numbness. Skin becomes initially red, then white and yellow, ultimately becoming black. Infection of the affected tissues may lead to the need for amputation. That is why frost bite should be given prompt medical attention.

1. Reamy BV. Frostbite: review and current concepts. The Journal of the American Board of Family Practice / American Board of Family Practice. Jan-Feb 1998;11(1):34-40.
2. Laroche GP. [Frostbite: review and new concepts]. L'union medicale du Canada. Dec 1978;107(12):1155-1157.
3. Rasmusen DL, Zook EG. frostbite: a review of pathophysiology and newest treatments. The Journal of the Indiana State Medical Association. Dec 1972;65(12):1237-1241.
4. Iukhtin VI, Klimiashvili AD, Smel'nitskii PS. [Diagnosis and treatment of frostbite]. Khirurgiia. Aug 1988(8):93-97.
5. Grieve AW, Davis P, Dhillon S, Richards P, Hillebrandt D, Imray CH. A clinical review of the management of frostbite. Journal of the Royal Army Medical Corps. Mar 2011;157(1):73-78.
6. Fuhrman FA, Fuhrman GJ. The treatment of experimental frostbite by rapid thawing; a review and new experimental data. Medicine. Dec 1957;36(4):465-487.
7. Gavinskaia NM. [Use of fibrinolysin and anticoagulants in complex treatment of frostbite]. Khirurgiia. Apr 1972;48(4):42-46.
8. Kotel'nikov VP. [Prevention and treatment of frostbite]. Meditsinskaia sestra. Mar 1981;40(3):13-16.
9. AIa G. [Prevention and treatment of frostbite]. Vestnik khirurgii imeni I. I. Grekova. Feb 1958;80(2):126-135.
10. Friberg O. [Prevention and treatment of frostbite injuries]. Duodecim; laaketieteellinen aikakauskirja. 1989;105(5):471-479.