Frostbite Treatment
All patients with frostbite should seek immediate medical attention, and the cornerstone of treatment is rapid rewarming in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, but only if there is no risk of refreezing. 1, 2
Immediate Field Management
Critical First Steps
- Remove all jewelry and constricting materials immediately from the affected extremity to prevent further injury as swelling develops 1, 2
- Assess for concurrent hypothermia first - if moderate to severe hypothermia is present, prioritize core rewarming before treating the frostbite 1, 2
- Protect the frostbitten tissue from further injury and strictly avoid walking on frozen feet or toes 1, 2
The Refreezing Rule
Do not attempt rewarming in the field if there is any possibility of refreezing - this is the most critical pitfall to avoid, as freeze-thaw-refreeze cycles cause significantly worse tissue damage than remaining frozen until definitive care 1, 2, 3, 4. Only rewarm if you can guarantee the tissue will remain thawed until reaching medical care.
Clothing Management
- Cut off saturated clothing in a protected environment before rewarming, as excess moisture renders warming ineffective 1
- Damp (but not saturated) clothing does not need to be removed 1
Rewarming Protocol
Water Temperature and Technique
- Use warm water immersion at 37-40°C (98.6-104°F) for 20-30 minutes - this temperature range is endorsed by five systematic reviews and multiple clinical practice guidelines 1, 2
- If no thermometer is available, test the water against your wrist - it should feel slightly warmer than body temperature 1
- Never use water above 40°C (104°F) as temperatures of 45°C (113°F) have been shown to cause harm in animal studies 1, 2
- Air rewarming can be used as an alternative when warm water immersion is not possible 1, 2
Superficial Frostbite Exception
For minor or superficial frostbite (frostnip), simple skin-to-skin contact with a warm hand is sufficient 2, 3
Post-Rewarming Care
Wound Dressing
- Apply bulky, clean, dry gauze or sterile cotton dressings to all affected areas and between fingers and toes 1, 2
- Wrap circumferential dressings loosely to accommodate swelling without compressing underlying tissue 1, 2
Pain and Tissue Protection
- Administer ibuprofen to prevent further tissue damage through inhibition of prostaglandin-mediated vasoconstriction and to treat pain 1, 2
- Continue NSAIDs long-term to prevent ongoing thromboxane-mediated dermal ischemia 5
What NOT to Do
- Do not debride blisters - this is explicitly not recommended for first aid providers 1, 2
- Do not use chemical warmers directly on frostbitten tissue as they can cause burns 2
Advanced Medical Treatment
Hospital-Based Interventions
For severe frostbite presenting within 24 hours, intravenous iloprost has FDA approval based on a randomized controlled trial showing significant reduction in bone scintigraphy abnormalities (0% with iloprost vs 60% with standard care) and subsequent amputations 6, 4. The trial protocol used iloprost IV for 6 hours daily for up to 8 days in patients with stage 3-4 frostbite 6.
Thrombolytic therapy with tissue plasminogen activator within 24 hours may also be beneficial for severe cases 6, 4
Special Populations
Diabetic Patients and Those with Neuropathy
- Do not assume absence of pain means absence of injury in patients with diabetes or peripheral neuropathy - their impaired sensation may prevent recognition of frostbite until visual inspection reveals tissue damage 2
- These patients are at higher risk due to pre-existing sensory deficits and poor circulation 2
- Assess vascular status early, as patients with toe pressure <30 mmHg or TcPO2 <30 mmHg have severely impaired wound healing and may require revascularization 3
Long-Term Sequelae Management
For chronic neuropathic pain following severe frostbite, duloxetine is recommended as first-line pharmacologic therapy, with gabapentin/pregabalin as second-line options 5. Topical combination gels should be avoided due to lack of efficacy evidence 5.