Merck Manual

Please confirm that you are a health care professional

honeypot link

Nonfreezing Tissue Injuries


Daniel F. Danzl

, MD, University of Louisville School of Medicine

Reviewed/Revised Dec 2022
Topic Resources

Acute or chronic injuries without freezing of tissue may result from cold exposure.


The mildest cold injury Overview of Cold Injury Exposure to cold may cause decreased body temperature ( hypothermia) and focal soft-tissue injury. Tissue injury without freezing includes frostnip, immersion foot, and chilblains. Tissue injury... read more is frostnip. Affected areas are numb, swollen, and red. Treatment is rewarming, which causes pain and itching. Rarely, mild hypersensitivity to cold persists for months to years, but there is no permanent damage to underlying tissues.

Immersion (trench) foot

Prolonged exposure to wet cold can cause immersion foot. Peripheral nerves and the vasculature are usually injured; muscle and skin tissue may be injured in severe cases.

Initially, the foot is pale, edematous, clammy, cold, and numb. Tissue maceration may occur if patients walk extensively. Rewarming causes hyperemia, pain, and often hypersensitivity to light touch, which can persist for 6 to 10 weeks. Skin may ulcerate, or a black eschar may develop. Autonomic dysfunction is common, with increased or decreased sweating, vasomotor changes, and local hypersensitivity to temperature change. Muscle atrophy and dysesthesia or anesthesia may occur and become chronic.

Immersion foot can be prevented by not wearing tight-fitting boots, keeping feet and boots dry, and changing socks frequently.

Immediate treatment is rewarming by immersing the affected area in warm (37 to 39° C) water, followed by sterile dressings. Nicotine should be avoided. Chronic neuropathic symptoms are difficult to treat; amitriptyline may be tried (see Neuropathic Pain: Treatment Treatment Neuropathic pain results from damage to or dysfunction of the peripheral or central nervous system, rather than stimulation of pain receptors. Diagnosis is suggested by pain out of proportion... read more ).

Chilblains (pernio)

Localized areas of erythema, swelling, pain, and pruritus result from repeated exposure to damp nonfreezing cold; the mechanism is unclear. Blistering or ulceration may occur. Chilblains most commonly affects the fingers and pretibial area and is self-limited. Occasionally, symptoms recur. Younger women are most commonly affected, some of whom may have Raynaud phenomenon Raynaud Syndrome Raynaud syndrome is vasospasm of parts of the hand in response to cold or emotional stress, causing reversible discomfort and color changes (pallor, cyanosis, erythema, or a combination) in... read more Raynaud Syndrome or underlying autoimmune disorders (eg, systemic or cutaneous lupus erythematosus).

Manifestations of Chilblains

Endothelial and neuronal damage results in vasospasm and exaggerated sympathetic response when exposed to cold. Nifedipine 20 mg orally 3 times a day, limaprost 20 mcg orally 3 times a day (not available in the US), or corticosteroids (oral, eg, prednisolone 0.25 mg/kg twice a day, plus topical corticosteroids) may be effective for refractory pernio. Sympatholytic drugs and avoidance of nicotine may also help.

General reference

  • 1. Dow J, Giesbrecht GG, Danzl DF, et al: Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med 30(4S):S47-S69, 2019. doi: 10.1016/j.wem.2019.10.002PMID: 31740369.

Drugs Mentioned In This Article

Drug Name Select Trade
Elavil, Tryptanol, Vanatrip
Adalat, Adalat CC, Afeditab CR, Nifediac CC, Nifedical XL, Procardia, Procardia XL
AK-Pred, AsmalPred, Econopred, Econopred Plus, Flo-Pred, Hydeltrasol, Inflamase Forte, Inflamase Mild, Millipred , Millipred DP, Millipred DP 12-Day, Millipred DP 6 Day, Ocu-Pred , Ocu-Pred A, Ocu-Pred Forte, Omnipred, Orapred, Orapred ODT, Pediapred, Pred Mild, Predalone, Pred-Forte, Prednoral, Pred-Phosphate , Prelone, Veripred-20
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
quiz link

Test your knowledge

Take a Quiz!