WHITE and Numb Fingertips
In sensitive individuals, after brief exposure to cold (within seconds) or during stress, one or more fingertips on one or both sides become pale and numb and then blue and then red; the attack may last from several minutes to hours (Raynaud’s phenomenon or syndrome).
Repeated use of vibration tools, such as hammer jack, may cause vibration white finger or hand-arm vibration syndrome (HAVS) with occasional numbness in the fingertips, which may become permanent with time. Fingertip discoloration does not occur during vibration but after exposure to cold or stress (Raynaud’s phenomenon–see above) 1.
Within 24 hours of using the hand as a hammer, the 3rd, 4th and 5th finger (or only one or two of them) and related part of the palm may suddenly become white or bluish, numb, cold and painful due to damage of the ulnar artery and nerve; the condition, which is known as hypothenar hand syndrome, may eventually improve; cold sensitivity may persist 2.
Frostnip. After prolonged exposure (minutes to hours) to cold, the hands and fingers may become cold, pale, bluish (cyanotic), stiff and, possibly, numb and tingly; reheating may trigger annoying pain in the nail beds 3.
Second-degree frostbite. After prolonged exposure to severe cold (hours, but can be minutes), the fingertips may become firm (“wooden”), waxy white, with eventual blisters developing 12-24 hours after the cold exposure; there is a loss of sensation for touch and, to some extent, for pain 6.
Third-degree burn or scald. After contact with hot objects, water vapors, the fingertips may become white with a leathery appearance and transient or permanent loss of sensation to touch and pain 4.
In arterial embolism, one or more fingers suddenly become cold, pale or blue, painful, weak, numb or tingly. Cramps may appear and the finger may be hard to move. If not treated promptly, ulcers or gangrene can develop 5.
Picture 1. Raynaud phenomenon
First phase of the attack: white fingers
Second phase: blue fingers
(source: Wikimedia, CC license)
Picture 2. Vibration white finger
due to working with hammer jack
(source: cdc.gov, Public Domain)
Contact with the stinging nettle leaves or stems usually causes burning, itchy, red patches (hives, urticaria); numbness may persist for more than 12 hours 7,8.
In sensitive people, contact with poison ivy, oak or sumac can cause an allergic reaction with red, burning, itchy and swollen skin; numbness and tingling may persist for several hours 9,10.
Deep second-degree burn or scald. After contact with a hot object, liquid or vapors, the affected fingertips are usually red and tender, but can later become more or less numb and remain so for up to a month 11,12.
Chilblains (pernio). In sensitive people, exposure of the fingers to nonfreezing temperatures below 60 °F (60 °C) and subsequent reheating may result in red or violaceous, blistering, itchy, tingly and numb fingertips or toes. Numbness usually goes away in one to three weeks or may persist for years 6,13.
A minor cut or puncture of the fingertip can result in felon or staphylococcal whitlow — an infection with red, swollen, painful and, eventually, numb fingertip pulp 14,15.
Stings of the venomous insects, such as a bee, wasp, hornet, spider (black widow, brown recluse spider) and scorpion, can cause burning pain, redness, blisters and swelling in the affected fingertip, followed by tingling and numbness, which may persist for a day or two 16,17,18.
Bites of non-venomous insects, such as a mosquito, horse fly, flea, scabies mites, bed bugs, lice, ticks, chiggers and cockroaches, can cause itchy red bumps, sometimes followed by tingling and numbness 19. NOTE: The exact site of the insect bite may not always be seen.
Bites of poisonous snakes, such as cobra or rattlesnake, to the arm can cause numbness and tingling in the affected area spreading toward the fingertips 20.
- In rheumatoid vasculitis (in rheumatoid arthritis and systemic lupus erythematosus or SLE), numbness and pits in the fingertips and red sores around the nails may develop 21,22.
- Symptoms of Churg-Strauss syndrome may include difficulty breathing (asthma), and red-bluish and numb fingertips 23.
One side effect of certain chemotherapeutics is hand-foot syndrome (acral erythema or palmar-plantar erythrodysesthesia) with numbness, tingling, pain, redness, swelling or flaking of the palms, fingers, soles and toes.
Picture 3. Chilblains
Red, swollen fingertips with big blisters
(source: Wikimedia, CC license)
Poisoning with elemental (metal) mercury in children: pink, numb or painful fingers, peeling hands and leg cramps (acrodynia) 24.
BLUE or PURPLE Fingertips
After an injury, for example, with a hammer, the affected fingertip usually becomes tender and bruised: red, then swollen and partially numb then dark blue-purple and then yellow-green.
Achenbach syndrome (paroxysmal hand hematoma, finger apoplexy) 25 consists of sudden pain, itching, stinging, swelling, coolness, bruising and, sometimes, numbness on the palmar side of one or, rarely, more fingers that last for few days and then resolve spontaneously. This benign condition is due to spontaneous bleeding in the finger. Triggers include physical work with hands, minor trauma, exposure to cold.
The affected individuals often have Raynaud’s phenomenon, migraine, chronic venous insufficiency (varicose veins), gallbladder disease, allergies or a blood disorder, such as anemia or thrombophilia. The condition may run in families. Blood and other tests are usually normal.
Cyanosis means bluish discoloration of the skin due to lack of oxygen in the tissues.
In peripheral cyanosis, fingers and toes, especially nail beds, and, sometimes, the skin around the mouth, but NOT lips and tongue, become bluish 26.
Peripheral cyanosis is caused by impaired circulation in the limbs.
Acute (sudden) peripheral cyanosis can be caused by 26:
- Cold injuries:
- Hypothermia due to prolonged immersion in cold water or exposure to cold air 27,29
- Chilblains 28
- Deep frostbite (persistent cyanosis and numbness after rewarming are bad prognostic signs) 30
- Raynaud’s phenomenon–see above under white fingertips
- Prolonged seizures (tonic-clonic seizures or grand mal epilepsy) 32
- Acute artery narrowing due to an embolus (due to atrial fibrillation, thoracic outlet syndrome) or crush injury (sudden pain, and cool, pale and, later, blue-purple fingers) 33
- Hypovolemic shock (due to severe dehydration, bleeding or diarrhea) or cardiogenic shock (due to heart attack, arrhythmia)
- Pheochromocytoma: cyanosis and tingling in the fingertips, finger tremor, pale skin, anxiety, high blood pressure 34
- Drugs: beta-blockers, methysergide, ergotamine, epinephrine and other drugs can increase the risk of Raynaud’s phenomenon with white, blue and red fingertips 35.
Some individuals experience sudden blue discoloration, coolness, swelling, pain (not always), numbness or “pins and needles” in one or more fingers without apparent reason. This is called “acute blue finger” or “blue finger syndrome” 31. Symptoms may last for few days and rarely recur. Possible risk factors include smoking, atherosclerosis, Raynaud’s phenomenon, trauma, frostbite, thoracic outlet syndrome, cryoglobulinemia and polycythemia. The condition is often benign, and the risk of thrombosis or embolism is low.
Chronic (persistent) peripheral cyanosis may be caused by 36:
- Atherosclerosis, mainly in older smokers and diabetics and those with high blood pressure and high blood cholesterol
- Venous thoracic outlet syndrome
- Vasculitis, for example, Buerger’s disease 39 and rheumatoid vasculitis 40
- Cryoglobulinemia (abnormal blood proteins causing blood clotting), for example, in hepatitis C 41
- Congestive heart failure
- Deep vein thrombosis or arterial thrombosis 42
Acrocyanosis is persistent bluish-purple discoloration of the fingertips (and sometimes, hands, feet, knees, nose, lips and nipples). Cyanosis is aggravated by cold or stress or by hanging hands down. There are no attacks, and cyanosis persists after rewarming. Other symptoms may include numbness in the fingertips and cool and sweaty palms. This benign condition, which tends to improve with time, is frequently seen in young women with anorexia nervosa; other causes include ovarian cancer, Hodgkin lymphoma, cryoglobulinemia, hypoxemia low oxygenation of the blood) 38. The risk of arterial occlusion or skin ulcers is not increased. In newborns, acrocyanosis is usually caused by metabolic disorders.
In central cyanosis, hands and feet, especially nail beds, lips, gums and tongue have bluish discoloration but are not cold (unless the causes of peripheral cyanosis are present) 26.
Central cyanosis is caused by decreased oxygenation of the blood:
Acute (sudden) central cyanosis 26:
- Lack of oxygen in the air (hypoxia) in high altitudes (climbers, pilots) 43
- Respiratory disorders: croup, whooping cough (pertussis), epiglottitis, bronchiolitis, severe attack of asthma, aspiration of vomitus, severe pneumonia, pulmonary edema, pulmonary embolism, tension pneumothorax, acute respiratory distress syndrome (ARDS)
- Heart disorders: heart attack, arrhythmia
- Methemoglobinemia: ingestion of or skin exposure to aniline, benzocaine, dapsone, pyridium, nitrites, nitrates, naphthalene, primaquine
- Sulfhemoglobinemia: an overdose of certain drugs (acetanilide, metoclopramide, nitrates, phenacetin, phenazopyridine, sulfasalazine, sulfonamides), ingestion of household cleansers (hydroxylamine sulfate) 26,44
- Disseminated intravascular coagulation (DIC), for example, in sepsis (see more causes below under Gangrene)
- Poisoning: solvents (chlorobenzene), pesticides (arsenic, strychnine, organophosphates) 45
Chronic (persistent) central cyanosis 26:
- Heart disorders: congenital disorders, cardiomyopathy, heart valve disease (infectious endocarditis, rheumatic fever, hypertension, aortic aneurysm) 42
- Respiratory disorders: chronic obstructive pulmonary disease or COPD (bronchitis, emphysema), bronchiectasis, pulmonary fibrosis, cystic fibrosis
- Severe anemia
- Blood hyperviscosity: Waldenström macroglobulinemia, polycythemia vera, multiple myeloma, leukemia, thrombocythemia, paraneoplastic syndrome in certain cancers 47
- Obstructive sleep apnea
- Genetic methemoglobinemia
Picture 4. Cyanosis
Blue fingertips and hand due to lack of oxygen in the blood
(source: Wikimedia, CC license)
In the third-degree frostbite, the affected fingertips become bluish-greyish or black and numb; superficial layers may peel off. Ulcers and an eventual permanent decrease of the fingertip sensitivity may develop 6,13.
In the fourth-degree frostbite, gangrene (tissue death) can occur, especially after freeze-thaw-refreeze situation 6,13.
In the fourth-degree burn, the fingertips carbonize and eventually crumble and fall off 4.
Gangrene means tissue death (necrosis); it is caused by blocked circulation, bacterial infection or trauma 48.
Dry gangrene can develop in severe atherosclerosis (in diabetes), vasculitis (for example, in Buerger’s disease), scleroderma or severe Raynaud’s disease 49.
Symptoms of dry gangrene: the affected fingertip becomes red, then pale, cold and numb, then brown, purple or black, it shrivels up and eventually fall off 48,51.
Wet gangrene can occur due to bacterial infection in severe frostbite, burn or injury.
Symptoms of wet gangrene: painful, swollen fingertips with foul-smelling discharge; the fingertips crumbles and eventually falls off (autoamputation) 48,51.
ACUTE gangrene of the fingertips 49,50:
- Tight wound dressing or splint immobilization of the finger 52
- Fourth-degree frostbite 6,13, third- and fourth-degree burn 4, electrical injury 53, irradiation injury (>5,000 rads)
- Severe injury to the finger, hand or arm 55, a cut of radial artery 56
- Artery occlusion after surgical artery ligation, a complication of surgery wound infection 57
- Infections: felon (cellulitis of the fingertip) 58, cellulitis of the hand, necrotizing fasciitis 59
- Prolonged contact with caustic potash, nitric, or sulfuric acid, spilling of diluted (1%) phenol (carbolic acid) solution over the skin 61
- Blood clot (thrombus) in deep venous thrombosis 62,63
- Hypersensitivity angiitis 50
- Necrotizing vasculitis: rheumatoid vasculitis, polyarteritis nodosa, Buerger’s disease 39
- Plague 64
- Disseminated intravascular coagulation (DIC) due to sepsis, leukemia, malaria, viral gastroenteritis, snake bites, transfusion reactions, recreational drugs, etc. with symmetrical peripheral gangrene affecting the fingertips and toes on both sides 65,66,67,68
- Gangrenous ergotism (the drug ergotamine, rarely: infected rye bread) 69,70
- A complication of chemotherapy (for example, the combination of bleomycin and methotrexate) 71
- Warfarin-induced skin necrosis 72
Picture 5. Gangrene of the fingertips in plague due to sepsis
CHRONIC causes of gangrene of the fingertips 49,50:
- Hyperglycemia in long-term, poorly controlled diabetes 1 or 2
- Arteriosclerosis (in older people, smokers, those with high cholesterol), eventually complicated by emboli lodged in the finger arteries 42
- Vasculitis: polyarteritis nodosa 73, Churg-Strauss syndrome (allergic vasculitis) 23,74, microscopic polyangiitis 75, rheumatoid vasculitis (SLE, rheumatoid arthritis) 76, Buerger’s disease (in heavy smokers) 39
- Hypereosinophilic syndrome 77
- Severe Raynaud’s phenomenon associated with scleroderma (CREST syndrome) or lupus 50,60
- Chronic disseminated intravascular coagulation (DIC) as a complication of ulcerative colitis, Crohn’s disease, leukemia, cancer, sarcoidosis, retained dead fetus syndrome 46
- Cryoglobulinemia, for example, in hepatitis C 41
- Antiphospholipid syndrome (APS), which may be associated with systemic lupus erythematosus (SLE) or other rheumatic diseases 37
- Thrombotic thrombocytopenic purpura (TTP) 72
- Patient.info (Hand-arm vibration syndrome)
- PMC (Hypothenar hammer hand syndrome)
- Emedicine (Frostbite)
- Mayo Clinic (Burn injury)
- Angiologist.com (Embolism in the upper extremity)
- Armypubs.army.mil (Cold injuries)
- Ucdavis.edu (Stinging nettle)
- Oardc.ohio-state.edu (Stinging nettle)
- Aad.org (Poison ivy, oak and sumac)
- Poison-ivy.org (Poison oak)
- Regionshospital.com (Pins and needles after a burn injury)
- Burns: Regenerative Medicine and Therapy, y.2004 (p.21) (Burns)
- Army.mil (Cold injuries)
- Bupa.co.uk (Felon complications)
- Drugs.com (Felon)
- MedlinePlus (Insect bites)
- MedlinePlus (Insect bites first aid)
- WebMD (Insect bites)
- Dermnetnz.org (Insect bites and stings)
- MedlinePlus (Snake bites)
- Clevelandclinic.org (Rheumatoid vasculitis)
- Nhlbi.nih.gov (Vasculitis)
- PMC (Churg-Strauss syndrome)
- EPA.gov (Mercury poisoning)
- Kampfen S et al, 2005, A Painful Blue Thumb: A Case of Achenbach’s Syndrome ScienceDirect
- Patient.info (Central and peripheral cyanosis)
- Wisc.edu (Cryoglobulinemia and acral cyanosis)
- Wiley.com (Primary amyloidosis and Raynaud’s phenomenon)
- Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition, y.2009, Volume 1 (p.1873) (Hypothermia)
- Emedicine (Frostbite)
- PMC (The acute blue finger)
- Devinski O, 2004, Effects of Seizures on Autonomic and Cardiovascular Function PubMed Central
- Practicalplasticsurgery.org (Crush injury)
- Healthlinkbc.ca (Pheochromocytoma)
- Japi.org (Antiphospholipid syndrome and Raynaud’s phenomenon)
- Vascularweb.org (Arm artery disease)
- PubMed (Antiphospholipid syndrome)
- Das S et al, 2013, Acrocyanosis: An Overview PubMed Central
- Emedicine (Buerger’s disease)
- Clevelandclinic.org (Rheumatoid vasculitis)
- Emedicine (Cryoglobulinemia)
- PubMed (Acute purple digits)
- Dedicated559.com (Hypoxia)
- PMC (Cleansers (hydroxylamine sulfate)
- Thebestcontrol.com (Strychnine, arsenic poisoning)
- Emedicine (Disseminated intravascular coagulation (DIC))
- Emedicine (Hyperviscosity syndrome)
- NHS.uk (Gangrene)
- Patient.info (Gangrene cause)
- PMC (Causes of gangrene)
- NHS.uk (Gangrene development)
- Acep.org (Tight wound dressing)
- Emedicine (Electrical burns)
- NIH.gov/books (Dissection of the thoracic aorta)
- PMC (Acute compartment syndrome of the forearm and hand)
- PubMed (A cut of radial artery)
- Oxfordjournals.org (Surgical wound infection)
- Bupa.co.uk (Felon complications)
- Emedicine (Necrotizing fasciitis)
- Mayo Clinic (Raynaud’s disease complications)
- Phenol first aid and PPE Cornell University
- PubMed (Gangrenous fingers)
- Natfonline.org (Deep venous thrombosis)
- Uiowa.edu (Gangrene in plague)
- PubMed (Venous thrombosis)
- PMC (Symetrical peripheral gangrene and disseminated intravascular coagulation)
- PubMed (Malaria)
- Emedicine (Disseminated intravascular coagulation)
- Drugs.com (Ergotamine)
- FPnotebook.com (Ergotism)
- PubMed (Chemotherapy)
- Orionwellspring.com (Blue toes and fingers)
- Emedicine (Polyarteritis nodosa)
- Mja.com.au (Churg-Strauss syndrome)
- Hopkinsvasculitis.org (Microscopic polyangiitis)
- Rheumatology.org (Gangrene of a finger in rheumatoid arthritis – picture)
- Jst.go.jp (Hypereosinophilic syndrome)