What causes persistently cold hands?

Why Are Hands Always Cold?

Persistently cold hands are most commonly caused by Raynaud's phenomenon, which results from excessive vasoconstriction in response to cold or stress, or by underlying arterial occlusive disease that impairs digital circulation. 1, 2

Primary Mechanisms

Raynaud's Phenomenon

• Raynaud's phenomenon is the leading cause of chronically cold hands, triggered by cold exposure or emotional stress that causes transient cessation of blood flow to the digits. 3, 1, 4
• The condition manifests as triphasic color changes: white (vasoconstriction), blue (cyanosis), and red (reperfusion), often accompanied by numbness, tingling, and pain. 4
• The pathophysiology involves increased sympathetic nerve activation, heightened sensitivity of adrenergic receptors on digital artery smooth muscle to cold, and possible deficiency of nitric oxide. 4
• Cold exposure is identified by patients as the main exacerbating factor, with more frequent and longer episodes during winter compared to summer. 3

Arterial Occlusive Disease

• In patients with Buerger's disease or arteriosclerosis obliterans, cold sensitivity results from impaired circulation due to occlusions in digital or proximal arteries, not from increased sympathetic response. 2
• Digital blood pressure measurements show significantly low pressures in fingers with cold sensitivity in arterial occlusion cases (90 of 91 affected fingers). 2
• If digital blood pressure is normal, arterial occlusive disease should not be considered the underlying cause. 2

Post-Traumatic Cold Intolerance

• Cold sensitivity develops in 50-100% of patients after hand injuries, replantation, or elective hand operations, presenting as numbness, stiffness, pain, discoloration, swelling, and reduced grip strength. 5
• The pathophysiology remains multifactorial and obscure, with symptoms either disappearing or exacerbating over time. 5

Physiological Response to Cold

• When metabolic rate is insufficient to maintain heat balance during cold exposure, the body drastically reduces blood flow to extremities, resulting in "physiological amputation" with extremity cooling toward ambient temperature. 6
• Dexterity decreases are caused by cooling of muscles and joints rather than effects on receptors or nerve conduction. 6

Practical Management Approach

For Raynaud's Phenomenon

• Use gloves and heating devices for the hands to decrease the burden of symptoms. 3, 1
• Avoid direct contact with cold surfaces and ensure thorough drying of the skin after washing. 3, 1
• Protect hands from sudden temperature changes, which are known triggers for vasospastic episodes. 3

General Cold Protection Strategies

• Wear appropriate gloves during cold exposure, though note that glove thickness may reduce dexterity while providing thermal protection. 6
• Maintain adequate metabolic rate through activity to support peripheral circulation. 6
• Avoid touching cold objects for prolonged periods, as contact coefficient and contact time determine freezing risk and dexterity reduction. 6

When to Investigate Further

Red Flags Requiring Evaluation

• Obtain digital blood pressure measurements using photoplethysmography if arterial occlusive disease is suspected. 2
• Consider underlying connective tissue disease (systemic sclerosis, lupus) if Raynaud's phenomenon is present, as these conditions frequently cause cold hands. 3
• Evaluate for secondary causes including collagen vascular diseases, which can present with Raynaud's phenomenon and cold sensitivity. 2

Distinguishing Primary from Secondary Causes

• In Raynaud's disease (primary), digital pressures are typically normal (only 5 of 123 affected fingers showed decreased pressure), but there is severe response to local cooling. 2
• In arterial occlusive disease, decreased digital pressure is the hallmark finding, with less severe response to cold challenge. 2

Common Pitfalls to Avoid

• Do not assume all cold hands are benign—arterial occlusive disease requires different management than Raynaud's phenomenon. 2
• Recognize that post-traumatic cold intolerance may be permanent and currently has no effective preventive measures or therapies. 5
• Understand that cold sensitivity after hand injury is extremely common and should be anticipated in patient counseling. 5