When A Patient Presents With A Painful Red Toe

Author(s): 
M. Joel Morse, DPM

   As winter approaches, patients must be aware of the punishing effects of cold on the lower extremity. Given that patients with feet affected by the falling temperatures may present more commonly to podiatric offices, a correct diagnosis and treatment are vital.

   Three patients presented with a single red, swollen, painful toe. I saw all patients individually but each had the same type of condition. For each patient, the condition had started several weeks before presentation with no obvious inciting cause. Each sought care from an internist, who placed the patients on antibiotics for a presumed toenail infection.

   I saw all patients during the same week. There was no unusual past medical history with these patients. Further discussion revealed that the only similarity between them was that all had been outside at the presidential inauguration in cold temperatures. The temperature during the January event was 19ºF with a wind chill making it a frigid 6ºF.

   It is very important that you really delve into the days before the occurrence of the foot problem. The fact that I was also at the inauguration was very helpful in making a diagnosis.

   All three patients wore regular sneakers with regular cotton socks. None thought it would be that cold and that they would be standing still for that amount of time. Two of the patients were fair skinned and in their 20s. One patient was in her 60s and had a history of Raynaud’s disease.

What You Should Know About Frostbite

   The three women had superficial frostbite. No laboratory test exists for frostbite as it is a clinical diagnosis.

   Whether patients are outside exercising or are spectators at an outdoor event, they need to consider not only the air temperature but the wind chill factor as well. In the cold, patients are in jeopardy because the skin and the tissues below the skin’s surface are made up of cells that contain water. In freezing temperatures, the water in the cells can freeze and the cells can die. Frostbite is tissue damage caused by freezing.

   Progressive symptoms of cold injuries include: initial coldness, stinging, burning and throbbing numbness followed by a complete loss of sensation. Other symptoms include: a loss of fine muscle dexterity (i.e., clumsiness of fingers); loss of large muscle dexterity (i.e., difficulty ambulating); and severe joint pain.

   There are three types of frostbite: frostnip, superficial frostbite and deep frostbite.

   Frostnip. Frostnip is a whitening of the tips of the fingertips and toes. It is slow to develop, is usually painless and seldom causes permanent tissue damage. Frostnip is not true frostbite, just super cold skin. It looks pale and feels cold. When the skin warms after frostnip, it may turn red. Underneath, the tissue is still warm and soft.

   The condition is not that serious and resolves by warming the foot/toe by moving and covering with extra layers of socks. It is also recommended that patients seek shelter and hold the toes between their hands to rewarm them until they appear normal again.

   Superficial frostbite. The term for cold damaged tissue that has not frozen solid is superficial frostbite. When one pushes carefully on the cold skin, it is still pretty soft. It looks like frostnip but when you rewarm it (the same way you rewarm frostnip), fluid-filled blisters develop. The skin is hard and frozen, and looks white/blue. The tissue underneath the skin has not been affected yet.

   As frostbite progresses or after the injured skin is warmed, the skin may be more pink or red than usual. The area will stay pink for several months although some people have permanent problems, such as pain, numbness and stiffness in the affected area.

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