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The occurrence of cold-related injuries depends on the degree of cold exposure, as well as environmental and individual factors. Frostbite is the prototypical freezing injury and is seen when ambient temperatures are well below freezing. Nonfreezing cold injuries occur as a result of exposure to wet conditions when temperatures are above freezing. The most common nonfreezing cold injuries are trench foot and chilblains. Although frostbite may result in permanent tissue damage, nonfreezing cold injuries are characterized by usually mild but uncomfortable inflammatory lesions of the skin. This chapter describes the occurrence, risk factors, treatment, and prevention of the nonfreezing cold injuries—trench foot and immersion foot, chilblains or pernio, panniculitis, and cold urticaria—and the freezing injury—frostbite.



Trench foot and its more severe variant, immersion foot, are rare conditions in civilians but can be a significant problem in military operations. The pathophysiology of trench foot is multifactorial but involves direct injury to soft tissue sustained from prolonged cooling, accelerated by wet conditions. The peripheral nerves seem to be the most sensitive to this form of injury.

Early symptoms progress from tingling to numbness of the affected tissues. On initial examination, the foot is pale, mottled, anesthetic, pulseless, and immobile, with no immediate change after rewarming. A hyperemic phase begins within hours after rewarming and is associated with severe burning pain and reappearance of proximal sensation. As perfusion returns to the foot over 2 to 3 days, edema and possibly bullae form, and hyperemia may worsen. Anesthesia frequently persists for weeks and may be permanent. In more severe cases, tissue sloughing and gangrene may develop. Hyperhidrosis and cold sensitivity are common late features and may persist for months to years. Severe cases may be associated with prolonged convalescence and permanent disability.1

Treatment is supportive, but vasodilator drugs may be tried. Oral prostaglandins can increase skin temperatures, which suggests improved circulation.2 Feet should be kept clean, warm, dryly bandaged, elevated, and closely monitored for early signs of infection. Prophylaxis for trench foot includes keeping warm, ensuring good boot fit, changing out of wet socks several times a day, never sleeping in wet socks and boots, and, once early symptoms are identified, maximizing efforts to warm, dry, and elevate the feet.


Chilblains, or pernio, are characterized by mild but uncomfortable inflammatory lesions of the skin caused by long-term intermittent exposure to damp, nonfreezing ambient temperatures. Symptoms are precipitated by acute exposure to cold.3 The most common areas affected are the feet (toes), hands, ears, and lower legs. Chilblains are primarily a disease of women and children, and although rare in the United States, the disease is common in the United Kingdom and other countries with a cold or temperate, damp climate.3 In addition, young females with Raynaud's ...

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