Jeremy Windsor on your essential outer layer.

Apart from a dusting of dandruff and the occasional shaving rash, most of us can’t really complain about our skin. Measuring up to three square metres, scientists - well, mostly dermatologists - grandly refer to our outer layers as, “the largest organ in the body” and wax lyrically about the vital functions it performs.

Not only is the skin an ideal waterproof storage container, but it is also regulates the body’s temperature to within a few degrees and refuses the menaces of various bugs and creepy crawlies. So if this skin of ours is really so wonderful, what is there to write about? Unfortunately, high on the mountainside our skin has a habit of failing, thanks largely to the environment it is exposed to and the extraordinary demands we place upon it. Despite the fuss made about cerebral oedema and depressed skull fractures, the majority of problems treated by your friendly expedition doctor are often only skin deep. However with some warning these are usually avoidable, often treatable and very photogenic.

What does the tip of the nose, a double chin and the soles of your feet have in common? The answer is that they’re all vulnerable to cold injury. Cold injury covers a host of conditions ranging from mild non-freezing cold injuries such as frost nip to deep frostbite capable of inflicting permanent damage to muscles, ligaments and bones. Although these injuries can occur almost anywhere on the body, they tend to favour areas missing a generous smear of fat (kneecaps, elbows and ears etc) and damp surfaces such as feet, various sweat patches and yes, the genitals.

The skin depends upon the body’s blood supply for fuel and heat. In conditions such as dehydration and hypothermia where the skin is deprived of water and warmth, the risk of cold injury rises dramatically. Tight fitting clothes and boots compound this by squeezing the skin and reducing the flow of blood. Blood flow can also be throttled by self inflicted punishments (tobacco and cocaine use), conditions found in the medical textbooks (you’ll know who you are from experience) and as a result of injuries picked up on the mountainside. Alarmingly, broken skin (that’s cuts, scratches and the like) are fifteen times more likely to suffer from cold injury than an identical area of healthy skin.
With non-freezing cold injuries occurring in damp conditions above 15°C, it is not surprising that most of us have some experience of their effects.

Remember the time when you’ve ploughed through steep, wet snow on a mild day in the Cairngorms and arrived at the belay with cold, numbed hands? No? Slowly your hands start to scream as warmth begins to return and you find yourself pole-axed by an unpleasant combination of nausea and pain! This is your first (and hopefully your last) experience of a non-freezing cold injury. Following a longer, colder period of exposure the skin is less forgiving. The sensation is now much slower to return and the pain persists for much longer. Soon, the skin begins to swell and turn an unpromising shade of red, before eventually blistering and shedding a thin layer of the skin’s surface.

The divide between frostbite (skin, fat and muscle that’s frozen solid) and the worst cases of frostnip are often blurred. In fact it’s quite common to see frostbitten hands and feet surrounded by an extensive ring of non-freezing injury when the casualty first arrives in hospital. Frostbite relies upon a combination of wind speed and air temperature for its effect. Above -10°C frostbite is rare except in the windiest of conditions, whilst below -25°C frostbite is common in even the most placid of situations. Frostbitten skin is numb, wooden and ghostly white. Surprisingly, in even the worst cases some movement may still be possible thanks to the efforts of warm tendons lying outside the injured area.

During the first week of recovery the skin reddens and blisters before a black charcoal-like carapace forms over the damaged area. This eventually separates after several weeks causing fingers, toes and sometimes even entire limbs to fall away leaving sensitive “baby” skin behind. Although frostbite injuries leave the most dramatic reminders, any cold injury can cause long term problems. These range from innocent short-lived patches of numbness or pins and needles to large areas of broken skin, criss-crossed with painful fissures that last for several years. Despite this enormous variation most sufferers agree on one thing: any old cold injury site always seems to be prone to the cold in the future.

The key to frostbite treatment is prevention. It really is stating the staggeringly obvious that on winter days anyone out in the mountains should expect the worst. Any winter rucksack must contain spare gloves, socks and warm layers to ward off the damp and cold, together with a generous supply of high energy foods and drinks to combat hypothermia and dehydration. Unfortunately frostbite still occurs and a clear idea of frostbite treatment might just save a couple of fingertips or worse. Once any part of the skin becomes numb it is vital to stop and warm up. If a change of clothes, some food and a good massage don’t help its time to turn back. It’s much safer to return to base camp on frozen feet than to make a half-hearted attempt at defrosting the offending area and risk them freezing again. The thawing of frostbitten limbs needs a bit of science for success: numb toes have a tendency to cook like sausages if held over a flickering flame whilst rubbing cold snow into the damaged areas just makes matters worse!

The longer the injured area remains frozen the poorer the chance of recovery. Therefore the safest and quickest way to thaw frozen areas is in a water bath, laced with a generous dose of antiseptic and heated to about 40°C or the temperature of a cool soak. Over thirty minutes most frozen tissues will begin to thaw and start to complain loudly. Painkillers (usually a mixture of paracetamol and morphine) and anti-inflammatory tablets (such as ibuprofen) are vital to control this, whilst an anti-tetanus injection and regular antibiotics (such as flucloxacillin or coamoxiclav) are needed to ward off infection. The thawed skin should be elevated, dressed with a sterile bandage and protected from the cold. Unfortunately these are only the first steps along a long road to recovery – the rest needs urgent hospital treatment.

On the South Col of Mt Everest temperatures can swing dramatically from -30ºC to +30ºC in little over an hour, exposing the skin to a bewildering combination of frostbite and sun damage in just a few minutes. UVB light (rather than heat itself) causes a wide range of mischief that varies from cold sores and allergic rashes to the all too familiar problem of sunburn. Sunburn is well known to most of us and tends to seek out hidden patches (the neck, bald spots and the calves) and overexposed areas (face and limbs) the most. However in the mountains UVB radiation throws up a few surprises. Reflected UVB rays are capable of striking from below, burning the dark recesses of the nostrils, eyelids, drooping chins and protruding ears. Whilst in clear, windy conditions UVB’s can also ride roughshod over areas normally immune to sunburn. One example of this occurs with trekking poles. These devices hold the hands taut and still for hours at a time allowing the skin to cook slowly before leaving a sunburnt surprise on the fingers and wrists of unsuspecting victims. Thankfully, the body is able to produce sunblock of its own.

Unfortunately many of us (and here I include all Anglo Saxons and not just lily white redheads) lack most of this machinery and need to rely upon bottled sources instead. In olden times the advice was to never use a sunblock, “less than a tennis score” (ie SPF 15) but now things have changed and most doctors wouldn’t dream of recommending anything less than factor 50 (SPF 50) – something akin to a boiler suit and a balaclava. To work effectively this needs to be liberally applied at least an hour before stepping out into the sun, massaged thoroughly onto clean skin and topped up regularly throughout the day (no mean feat!). Although some can cope with this demanding skincare regime most of us can’t be bothered. Instead, the undisciplined are faced with two choices – either cover up with gloves, scarves and hats or familiarise yourself with the contents of the nearest first aid kit.
The key to treating sunburn is to use a really good emollient.

This is not as painful as it sounds, as an emollient is really just a “medicalised” moisturising cream. Where these differ from the potions that line the supermarket shelves is that they’re designed specifically for injured or sensitive skin. This means that perfumes, alcohol and anti-wrinkle agents are binned leaving instead a bland, colourless cream in its place that has the appearance and consistency of something between milk and butter. On sunburn, a generous fingertip of E45 or Aqueous Cream will be enough to cover an area the size of your hand and dampen the most glaring sunburn within a few hours. Emollients not only prevent pain and acute embarrassment but they can also ward off infection. By restoring moisture to the skin, the outermost layers are quickly repaired and eager bacteria are prevented from invading the damaged surface and causing cellulitis. Without antibiotics, cellulitis has a habit of tiptoeing up the limbs and into the bloodstream. Clearly this can have serious consequences and often leads to a lengthy hospital stay.

Despite the ravages of frostnip and sunburn the skin is still expected to soldier on. Feet trapped in new boots can bruise and blister within a few steps and leave victims wondering how they’ll make it through the rest of a long expedition. Despite the efforts of many, the Himalayas have not been shown to be the ideal testing ground for new footwear. Instead comfortable, shabby gear rules the roost over gleaming new top-of-the-range equipment.

Feet need to be checked each day for sores and blisters and on the first signs of discomfort the offending areas should be covered with a fabric plaster or synthetic “second skin” (available from all good pharmacists). Infection loves to grow under the confines of a sweaty plaster so it’s crucial that these areas are not ignored. Conditions such as athlete’s foot, in-growing toenails and warts all have a habit of spreading at an alarming rate in sweaty boots, making it essential that these are all sorted out before departure. In hot and sweaty conditions collections of pus (abscesses) form under the skin surface and resist the advances of our trusty antibiotics.

Unfortunately, as anyone with a bit of surgical knowledge will tell you, “if there’s pus about cut it out” and a small operation is often the only solution. However performing minor surgery is often impractical and not helped by the fact that on a mountainside open wounds attract bacteria and infection with consummate ease. Instead it’s probably better to keep the area clean and protected and allow it to burst in its own time. However if the abscess makes it impossible to walk there’s bound to be someone around who’s prepared to plunge in with a sterile blade and relieve the pressure. The remaining wound will need careful attention: a daily wash with antiseptic, regular dressing changes and a course of antibiotics will all be needed in order to stem the spread of infection.

The combination of swinging temperatures and taxing physical work can also cause painful splits in the fingertips. These fissures or “Polar Hands” were first described in Antarctica and were found to heal nicely with the careful application of medical “superglue”. Superglue can also be used to treat a wide range of small cuts and lacerations. However anything more than a few centimetres long will need stitches – a useful skill to have, but beyond the scope of this article!

Armed with modern climbing equipment, a well stocked first aid kit and a good supply of knowledge you’re almost certain to have a healthy and safe expedition. However life can be very different for those porters and guides who climb alongside you. As employers and mountaineers we have a responsibility to ensure that these men and women are suitably dressed and given the same medical treatment as anyone else. However don’t be surprised if your offer of sunblock is greeted with smiles and laughter! On a different note it’s worth remembering that when the blisters are aching and your thoughts turn towards the comforts of home you’re in the finest of company.

Here, the expedition doctor Peter Steele recalls the sight of Don Whillans, arguably one of Britain’s finest mountaineers, “He arrived nearly a month after the main party in appalling physical condition with a beer drinkers paunch that overflowed the tops of his trousers, the top button he was unable to fasten. After the first half day of walking he was nursing his blisters and coughing away the emanations of the pungent little cigars he smoked continually. His pace, when he could not avoid walking, was very slow and on arrival in camp he would sit for hours outside the tent doing nothing but contemplate.”

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