What is the appropriate long‑term outpatient management for a patient who has sustained frostbite?

Long-Term Outpatient Management of Frostbite

Continue ibuprofen long-term (400-600 mg every 6-8 hours) to prevent ongoing prostaglandin and thromboxane-mediated vasoconstriction and dermal ischemia, and arrange prompt specialist follow-up within 24-48 hours for wound monitoring and functional rehabilitation. 1, 2

Immediate Post-Acute Phase (First 2-4 Weeks)

Wound Care and Protection

• Apply bulky, clean, dry gauze or sterile cotton dressings loosely circumferentially to affected areas, placing material between all digits to prevent maceration and pressure injury 1, 2
• Change dressings regularly to maintain intact skin barriers and prevent infection 2
• Protect affected extremities from mechanical trauma, pressure sores, and any risk of refreezing 1
• Do not debride intact blisters as they serve as a natural barrier against infection 1

Pharmacologic Management

• Continue ibuprofen 400-600 mg every 6-8 hours indefinitely to reduce ongoing vasoconstriction and dermal ischemia 1, 2
• This anti-inflammatory and anti-thrombotic effect is critical for preventing progressive tissue damage beyond the acute phase 1

Specialist Follow-Up

• Arrange podiatry or hand surgery follow-up within 24-48 hours for moderate injuries, sooner if deeper tissue involvement is suspected 1
• Deep frostbite may require burn center care as severity can be difficult to assess initially 1
• Surgical decisions (debridement, amputation) should be delayed until clear demarcation of viable versus non-viable tissue occurs, which may take weeks 3

Long-Term Management (Weeks to Months)

Monitoring for Complications

Instruct patients to return immediately for:

• Increasing pain, numbness, or color changes 1
• Development of new blisters or tissue breakdown 1
• Signs of infection (warmth, erythema, purulent drainage) 1
• Vasomotor disturbances or cold sensitivity 4

Functional Rehabilitation

• Physical therapy should be initiated once wounds are stable to restore range of motion and strengthen affected extremities 3
• Continuous management is needed to achieve functional recovery even after wounds have healed 3
• In children, monitor for epiphyseal cartilage damage that can lead to bone deformities requiring long-term orthopedic follow-up 4

Chronic Sequelae Management (Months to Years)

Neuropathic Pain

For chronic neuropathic pain following severe frostbite, duloxetine is the first-line pharmacologic therapy. 2

• Duloxetine has moderate strength evidence showing benefits equal to harms for neuropathic pain 2
• Gabapentin/pregabalin may be considered as second-line options, though evidence outside clinical trials is insufficient 2
• Tricyclic antidepressants such as amitriptyline may have some benefit but evidence is limited 2, 4
• Avoid topical combination gels (baclofen, amitriptyline, ketamine) due to lack of efficacy evidence 2

Vasomotor Disturbances

• Patients commonly develop cold sensitivity and susceptibility to refreezing in previously frostbitten areas 4
• Botulinum toxin type A (BTX-A) injections have been reported beneficial for vasomotor and neuropathic disturbances secondary to frostbite 4
• Epidural sympathetic block may be used for short-term treatment of frostbite-induced chronic pain 4

Skeletal Complications

• Frostbite arthritis clinically resembles osteoarthritis and should be managed accordingly 4
• Long-term orthopedic monitoring is essential, particularly in pediatric patients at risk for growth plate damage 4

Patient Education and Prevention

Critical Counseling Points

• Educate patients about permanent increased susceptibility to cold injury in previously frostbitten areas 4
• Emphasize absolute avoidance of re-exposure to cold environments without adequate protection 3
• Counsel on proper protective equipment (insulated gloves, boots, face protection) for any future cold exposure 3

Common Pitfalls to Avoid

• Do not discontinue ibuprofen prematurely—ongoing anti-inflammatory effects are needed long-term 2
• Do not rush to surgical amputation—allow adequate time (weeks to months) for demarcation of viable tissue 3
• Do not assume absence of pain means absence of ongoing injury, especially in patients with diabetes or peripheral neuropathy who may have baseline reduced sensation 1
• Do not use gabapentin/pregabalin as first-line therapy for neuropathic pain—duloxetine is preferred 2