What could be the cause of a burning sensation with skin that is cool to the touch and how should it be managed?

Burning Sensation with Cool Skin: Differential Diagnosis and Management

A burning sensation with skin that is cool to the touch most likely represents a neuropathic dysesthesia caused by small nerve fiber dysfunction, not a thermal burn, and requires neurologic evaluation rather than burn treatment. 1, 2

Key Distinguishing Features

This presentation is fundamentally different from thermal burns, where the affected skin is warm or hot to touch 3. The cool temperature indicates this is a sensory nerve problem, not tissue injury from heat 2.

Primary Diagnostic Considerations

Paradoxical heat sensation (PHS) is the most likely explanation when patients perceive burning while the skin remains cool 2. This occurs in approximately 30% of patients with neuropathic conditions compared to only 2% of healthy individuals 2.

Small fiber neuropathy is the underlying mechanism, characterized by:

• Loss of thermosensory fiber function normally involved in temperature perception 2
• Lower sensitivity to thermal stimuli despite burning sensations 2
• Reduced sensitivity to normally painful heat and cold 2

Other Neuropathic Dysesthesias to Consider

Cutaneous dysesthesias present as burning, tingling, stinging, or abnormal sensations in well-defined locations without visible skin pathology 1. These result from nerve trauma, impingement, or irritation 1.

Erythromelalgia variant may present with facial burning and erythema, though typically the affected area shows increased temperature during episodes 4. The cool skin in your case makes this less likely 4.

Clinical Evaluation Algorithm

Immediate Assessment

• Verify skin temperature objectively with thermometer or infrared device to confirm coolness 4
• Examine for visible skin changes: absence of erythema, blistering, or tissue damage rules out thermal injury 3
• Assess distribution: dermatomal or nerve territory patterns suggest specific nerve involvement 1

Neurologic Examination

• Test sensory modalities: light touch, pinprick, temperature discrimination, and vibration 2, 5
• Document specific deficits: patients with PHS demonstrate significantly lower sensitivity to thermal perception 2
• Check for allodynia: pain from normally non-painful stimuli indicates central sensitization 5

Historical Red Flags

• Previous burn injury: even healed burns can cause chronic dysesthesias years later, with significant sensory losses in both burned and unburned areas 5, 6
• Diabetes or metabolic disorders: polyneuropathy is more frequently associated with PHS 2
• Recent trauma or surgery: nerve impingement or irritation may trigger dysesthesias 1

Management Strategy

When Thermal Burn is Definitively Ruled Out

Do not apply burn treatment protocols (cooling, antibiotic ointments, burn dressings) as these are inappropriate for neuropathic conditions 3, 7.

Initiate neuropathic pain management:

• Gabapentin as first-line therapy for neuropathic burning 4
• NSAIDs (indomethacin) for inflammatory component 4
• Topical lidocaine compounds for localized relief 4
• Combination therapy often provides better control than monotherapy 4

Specialist Referral Indications

Neurology consultation is essential for:

• Quantitative sensory testing to document small fiber dysfunction 2, 5
• Nerve conduction studies if large fiber involvement suspected 1
• Skin biopsy for intraepidermal nerve fiber density if diagnosis unclear 2

Dermatology evaluation if:

• Any visible skin changes develop 1
• Concern for underlying dermatologic condition 1

Critical Pitfalls to Avoid

Do not dismiss as psychogenic: PHS and dysesthesias have documented neurophysiologic basis with measurable sensory deficits 2, 5.

Do not delay evaluation: chronic neuropathic pain becomes more difficult to treat over time, and early intervention improves outcomes 5.

Do not assume absence of pain means no pathology: PHS frequency is not linked to pain presence or intensity, and many patients have sensory deficits without pain 2.

Do not overlook systemic causes: polyneuropathy, diabetes, and metabolic disorders require identification and treatment of underlying conditions 2.

Special Populations

Post-burn patients may develop chronic dysesthesias even in unburned areas due to central nervous system changes, with incomplete recovery of sensation persisting years after injury 5, 6. These patients require long-term monitoring and may benefit from combination neuropathic pain management 4, 5.

Elderly patients have higher risk of chronic sensory problems and may require lower initial medication doses with careful titration 5.