Definition

Wounds resulting from cold injuries are traumatic injuries caused by exposure to extreme cold temperatures, which can lead to tissue damage, loss of body parts, and even death. These injuries can occur with or without the freezing of body tissue. Examples include:

• Chilblains. An inflammation of small blood vessels in the skin due to repeated cold exposure that does not freeze. Also known as pernio or perniosis, chilblains cause itchiness, red or bluish rashes, swelling, and blisters on the hands and feet.
• Frostbite. An injury resulting from the freezing of the skin and underlying tissues due to cold exposure. It commonly affects extremities such as fingers, toes, ears, and nose.
• Ice Burns. These occur when ice or other cold objects contact and damage the skin, typically after prolonged exposure to cold temperatures, such as from applying a cold compress directly to the skin for an extended period.

Causes

Chilblains.

Exposure to cold temperatures can cause small blood vessels to constrict. Normally, the body's reflex will periodically dilate these vessels to maintain blood supply to the skin. However, persistent and prolonged constriction because of an abnormal reaction to cold can lead to hypoxemia (low oxygen levels in the blood) and inflammation, resulting in chilblains.

Frostbite

Frostbite occurs when the skin is exposed to cold temperatures or cold water. It can also develop from exposure to moderately cold temperatures over a longer period. Ice packs and cold metal can cause frostbite if pressed directly against the skin, or even from contact through clothing, such as gloves. The freezing of water content in the skin leads to cell and tissue damage, typically affecting fingers, toes, and ears first. Frostbite can injure not only the skin but also the underlying tissues, including muscles, nerves, and joints.

Ice Burns

Ice burns happen when the skin comes into direct contact with ice or other extremely cold objects for an extended period. Cold compresses or ice packs used for treating muscle pain and other injuries can cause ice burns if applied directly to the skin for too long. Prolonged exposure to snow, cold weather, or high-speed winds can also result in ice burns.

Risk factor

Several factors can increase the risk of developing cold injuries:

Chilblains

• Wearing tight clothing or exposing the skin to cold and damp conditions
• Living in humid climates
• Smoking
• Female
• Overweight or underweight
• Poor blood circulation
• Lupus
• Suffering from Raynaud's Phenomenon
• Bone marrow disorders, such as chronic myelomonocytic leukemia

Frostbite

• Medical conditions like fatigue, dehydration, circulatory disorders, diabetes, hunger, and malnutrition
• Mental illness, panic, or fear, which can affect decision-making in cold temperatures
• Smoking, alcohol consumption, or drug abuse
• Certain medications such as beta-blockers
• Prior medical history of frostbite
• Age, infants and the elderly have more difficulty retaining body heat
• Wearing tight clothing or footwear
• Exposure to cold and windy weather
• Living at high altitudes, the risk increases due to low temperatures and reduced oxygen levels

Ice Burns

• Prolonged exposure to cold or windy weather without proper attire
• Smoking
• Taking medications that reduce blood flow to the skin, such as beta-blockers
• Having diabetes, blood vessel disease, or other conditions affecting blood circulation
• Having peripheral neuropathy or conditions that reduce the ability to detect injuries
• Fragile skin, making children and the elderly more susceptible to ice burns

Symptoms

Chilblains 

The signs and symptoms of chilblains may include:

• Small, itchy red rashes on the skin, often can be found on the feet or hands
• Blisters (fluid-filled vesicles) on the skin
• Skin swelling
• A burning sensation on the skin
• Changes in skin color from red to dark blue, accompanied by pain

Frostbite 

Frostbite typically affects the fingers, toes, nose, ears, cheeks, and chin. Symptoms of frostbite include:

• Initially, cold and prickling sensations on the skin can occur
• Skin numbness
• Skin discoloration (red, white, bluish-white, grayish-yellow, purplish, brown, or pale, depending on severity and normal skin color)
• Hard or waxy skin appearance
• Joint and muscle stiffness

Frostbite occurs in several stages:

• Frostnip. A mild form of frostbite that can cause numbness due to prolonged cold exposure. As the skin warms, pain and tingling may occur. Frostnip does not cause permanent damage.
• Superficial frostbite. This type occurs in the superficial layer of skin, causing slight changes in skin color. Rewarming of skin may result in mottled skin, stinging, burning, and swelling. Vesicles may appear 12 to 36 hours after warming the skin.
• Deep frostbite. A severe type of frostbite affecting all skin layers and underlying tissue. The skin turns white or blue-gray, causing sensory loss (sensation of cold, pain or discomfort) in the affected areas. Joints or muscles may stop functioning, and large blisters form 24 to 48 hours after rewarming the skin. The tissue may turn black and hard in necrosis.

Ice Burns 

Ice burns often resemble other types of burns, such as sunburns. Symptoms may include discoloration of the affected skin (bright red, white, or yellowish-gray). Other symptoms are:

• Numbness
• Itchiness
• Tingling sensation
• Pain
• Blisters
• Tight or waxy skin

Diagnosis

In diagnosing cold injuries, a doctor will begin with a detailed interview to gather information about the symptoms, duration of symptoms, and potential contributing factors of the injuries such as history of exposure to cold and any existing medical conditions. The doctor will follow-up this information by performing a physical examination of the affected area. While many cold injuries can be diagnosed based on clinical appearance and interview findings, additional tests may be recommended to assess the extent of tissue damage. These diagnostic tests can include blood tests, X-ray or MRI scans, and skin biopsies.

Management

Chilblains

Initial treatment of chilblains involves keeping the affected areas warm and dry. Managements include wearing gloves and socks and changing damp gloves and socks as needed. Medications used in treatment are:

• Nifedipine
• Corticosteroid cream

Frostbite

Treatment for frostbite may include:

• Rewarming the affected skin in warm water for 15 to 30 minutes.
• Painkillers, antibiotics, and thrombolytics can be prescribed by the doctor.
• Covering the affected skin after rewarming the skin and elevating the affected body area to reduce swelling.
• Debridement, removal of damaged tissue.
• Hydrotherapy or physical therapy.
• Wound care.
• Surgical procedure.
• Hyperbaric oxygen therapy.

Ice Burns

Treatment for ice burns involves:

• Remove sources of cold and gently warm the skin:
• Soak the affected area in warm water (40˚C-42.2˚C) for 20 minutes.
• Repeat the soaking process if necessary, with 20-minute rest intervals between soaks.
• Use a warm compress or blanket to maintain warmth in addition to soaking the skin.

• If there are blisters or open wounds, clean the area thoroughly and bandage the wound to keep it free from dirt and germs.
• Take painkillers as needed to manage discomfort. Once the skin begins to heal, apply aloe vera or another soothing gel to help relieve discomfort.

Complications

Chilblains can lead to complications if blisters form, as this increases the risk of infection.

Complications from frostbite may include:

• Increased sensitivity to cold
• Higher risk of recurrent frostbite
• Persistent numbness in the affected area
• Excessive sweating
• Changes in skin color
• Changes or loss of nails
• Joint stiffness
• Infection
• Tetanus
• Gangrene, which involves tissue decay and death due to disrupted blood flow, potentially leading to amputation
• Hypothermia

Complications of ice burns involve the development of scar tissue. The likelihood of scarring is influenced by the size of the affected area and the number of tissue layers involved.

Prevention

Chilblains

There's no surefire way to prevent chilblains, but you can reduce the risk by:

• Avoiding cold and damp environments.
• Exercising regularly to improve blood circulation.
• Quitting smoking.
• Wearing layers of warm clothing in cold weather, covering the feet, hands, and ears.

Frostbite

Take the following steps to prevent frostbite:

• Avoid spending long periods in cold weather and direct contact with metal surfaces or water in cold weather.
• Dress appropriately for cold weather. Wear gloves, a hat that covers your ears, a scarf, sunglasses, or a ski mask if needed. Outerwear must be waterproof and windproof.
• Change out of wet clothes as soon as possible.
• Stay hydrated and eat nutritious food.
• Recognize the signs of frostbite and seek medical attention immediately if you experience it.

Ice Burns

To prevent ice burns, avoid direct skin contact with cold objects. For example, when applying a cold compress, wrap the ice in a towel before placing it directly on the skin. It's also important to dress appropriately in cold weather and properly protect your skin from high-speed winds.

When to see a Doctor?

Immediately consult a doctor if you experience symptoms due to cold injuries.

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