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Cutaneous Cold Weather Injuries in the US Military

In Partnership With the Association of Military Dermatologists
Cutis. 2021 October;108(4):181-184,202 | doi:10.12788/cutis.0363
October 6, 2021|Cutis
Robert A. Kowtoniuk, DO;Yizhen E. Liu, MD;Jonathan P. Jeter, MD
Author and Disclosure Information

Dr. Kowtoniuk is from the Department of Dermatology, San Antonio Uniformed Services Health Education Consortium, Texas. Dr. Liu is from 75th Medical Group, Hill Air Force Base, Utah. Dr. Jeter is from the Department of Dermatology, William Beaumont Army Medical Center, Fort Bliss, Texas.

The authors report no conflict of interest.

The views expressed in this article are those of the authors and do not reflect the official policy or position of William Beaumont Army Medical Center, the Department of the Army, the Defense Health Agency, or the US Government.

Correspondence: Jonathan P. Jeter, MD, William Beaumont Army Medical Center, 18511 Highlander Medics St, Fort Bliss, TX 79918 (jonathan.p.jeter.mil@mail.mil).

Service members of the US Military are at risk for cutaneous cold weather injuries due to the demands of military training, combat operations, and peacekeeping missions. In this article, we review common cutaneous cold weather injuries likely to be encountered in the military, including frostbite, immersion foot, pernio, Raynaud phenomenon (RP), and cold urticaria. We aim to bring awareness to these specific injuries to improve diagnostic and treatment outcomes, both in service members and civilians.

Practice Points

  • Military service members are at an increased risk for cutaneous cold weather injuries in certain circumstances due to the demands of military training and combat operations.
  • Cold weather may cause injury by directly damaging tissues, leading to neurovascular disruption, and by exacerbating existing medical conditions.

Pernio

Pernio is another important condition that is related to cold exposure; however, unlike the previous 2 conditions, it is not necessarily caused by cold exposure but rather flares with cold exposure.

FIGURE 1. A and B, Pernio that first occurred years prior in a soldier who spent 2 days at a shooting range in the snow while stationed in Germany. The skin on the toes was mildly cyanotic and there were scattered bullae.

Case Presentation—A 39-year-old active-duty male service member presented to the dermatology clinic for intermittent painful blistering on the toes of both feet lasting approximately 10 to 14 days about 3 to 4 times per year for the last several years. The patient reported that his symptoms started after spending 2 days in the snow with wet nonwinterized boots while stationed in Germany 10 years prior. He reported cold weather as his only associated trigger and denied other associated symptoms. Physical examination revealed mildly cyanotic toes containing scattered bullae, with the dorsal lesions appearing more superficial compared to the deeper plantar bullae (Figure 1). A complete blood cell count, serum protein electrophoresis, and antinuclear and autoimmune antibodies were within reference range. A punch biopsy was obtained from a lesion on the right dorsal great toe. Hematoxylin and eosin–stained sections revealed lichenoid and vacuolar dermatitis with scattered dyskeratosis and subtle papillary edema (Figure 2). Minimal interstitial mucin was seen on Alcian blue–stained sections. The histologic and clinical findings were most compatible with a diagnosis of chronic pernio. Nifedipine 20 mg once daily was initiated, and he had minimal improvement after a few months of treatment. His condition continued to limit his functionality in cold conditions due to pain. Without improvement of the symptoms, the patient likely will require medical separation from military service, as this condition limits the performance of his duties and his deployability.

FIGURE 2. A and B, Histopathologic findings of chronic pernio observed from punch biopsy on hematoxylin and eosin–stained sections, which revealed a lichenoid and vacuolar dermatitis with scattered dyskeratosis and subtle papillary edema (original magnifications ×40 and ×100). Reference bars indicate 600 μm and 300 μm, respectively.

Clinical Discussion—Pernio, also known as chilblains, is characterized by cold-induced erythematous patches and plaques, pain, and pruritus on the affected skin.18 Bullae and ulceration can be seen in more severe and chronic cases.19 Pernio most commonly is seen in young women but also can be seen in children, men, and older adults. It usually occurs on the tips of toes but also may affect the fingers, nose, and ears. It typically is observed in cold and damp conditions and is thought to be caused by an inflammatory response to vasospasms in the setting of nonfreezing cold. Acute pernio typically resolves after a few weeks; however, it also can persist in a chronic form after repeated cold exposure.18

Predisposing factors include excessive cold exposure, connective tissue disease, hematologic malignancy, antiphospholipid antibodies in adults, and anorexia nervosa in children.18,20,21 More recently, perniolike lesions have been associated with prior SARS-CoV-2 infection.22 Histologically, pernio is characterized by a perivascular lymphocytic infiltrate and dermal edema.23 Cold avoidance, warming, drying, and smoking cessation are primary treatments, while vasodilating medications such as nifedipine have been used with success in more resistant cases.20,24

Although the prognosis generally is excellent, this condition also can be career limiting for military service members. If it resolves with no residual effects, patients can expect to continue their service; however, if it persists and limits their activity or ability to deploy, a medical retirement may be indicated.11-14

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