Purple toes and feet

Purple Feet

Purple feet are very common. In some people the color is so dark they almost look black. Purple feet can be a sign of poor circulation. But they don’t have to be a sign of anything dangerous.

Acrocyanosis of the legs, courtesy of Steven Dean, DO.

Purple Feet from Poor Circulation

Poor circulation is not a medical term. It can mean many things. But purple feet from poor circulation means there are artery blockages. Artery blockages that are severe enough to cause purple feet need to be diagnosed and treated quickly.

Artery blockages can sometimes also result in blue toes. It may surprise you to find out that purple toes can actually be more severe than when the whole foot is purple. Sometimes blue toes are a sign of particles that block the arteries. These particles may signify a serious clotting porblem. Sometimes they signify a risk for other serious issues like stroke.

Purple Feet from Acrocyanosis

Acrocyanosis is simply Latin for blue extremity. This is the most common cause for purple feet.

Acrocyanosis of both feet

Acrocyanosis disappears after elevation

There are two types of acrocyanosis: Primary and secondary. Primary is the most common. It simply means there is no underlying cause. Sometimes it is just a result of cold feet. Primary acrocyanosis results in purple feet that resolve when the feet are made warmer or elevated. Secondary acrocyanosis means that there is an underlying cause. It can be a disease or medication.

Purple Feet from Low Blood Pressure

For blood to reach the feet the heart needs to work properly and there needs to be adequate blood pressure. In states of heart failure or very low blood pressure the feet may not receive enough blood. Sometimes medications that are meant to elevate the blood pressure constrict artery flow. This can artificially cause poor circulation to the feet. All these can result in purple feet.

Purple Feet from Vein Disease

In general there are two types of vein disease in the legs and both can result in purple feet:

  • Blood clots – These are also known as deep vein thrombosis or DVT. If the DVT is very extensive, it can prevent blood from returning properly to the body. Blood ends up pooling in the feet. Blood that pools looses its oxygen and turns blue. This may cause the feet to seem purple. If the clot is even worse it can elevate the pressure in the leg to block artery flow. If that happens that is called phlegmasia. Then the whole leg can seem purple.
  • “Leaky” valves – Veins are supposed to take blood from the feet to the body. This is against gravity. To make this system work, veins have valves. If the valves malfunction, some of the blood pools in the feet. This is also called venous insufficiency. As before, pooled blood can loose its oxygen and look blue. Also, patients with leaky valves tend to have dilated bluish veins. These are called reticular veins. Clusters of these veins can make the foot seem blue.

Subscribe to the World’s Most Popular Newsletter (it’s free!)

Prior to the appointment with Dr. Dickholtz, Sr., I completed an extensive health history profile. One of the first questions on the health history was, had I ever had a head injury? I thought, “Who hasn’t hit their head?” Then I remembered four memorable head injuries throughout my life. The most serious one took place a year prior to CFIDS and the most recent one occurred six months before seeing Dr. Dickholtz, Sr.

My initial appointment with Dr. Dickholtz, Sr. was extensive. After looking at the completed health history, he did six different kinds of tests to determine the problem. He asked me to sit in a chair, while he used a neurocalometer that measured the temperature difference of each side of my cervical spine (from the shoulders to the base of the skull). He also performed a supine leg check, which measured leg length differences in relationship to muscle spasms that occurs on each side of my body. Another test involved standing on an anatometer, which looked at a posture scan in relationship to my hip level and pelvic rotation position. There was a horizontal line chart that showed the level of the ears in the standing position relative to the talking of three X-rays, when seated, of the cervical spine and skull that were taken lastly.

After all the tests were performed, Dr. Dickholtz, Sr. examined and measured the X-rays and determined the proper adjustment needed to return my spine and head to a balanced position. Through the X-ray measurements, he was able to return the C1 (atlas) and the rest of the vertebrae to within a quarter degree of their proper positions.

Once the specific chiropractic adjustment was performed, it took my body time to acclimate before standing without feeling faint. When able, I walked the length of the exam room a couple times allowing my body to rebalance itself from the adjustment (correction). Before the four-hour appointment was completed, all six of the above tests were performed again and post X-rays taken to make sure that the adjustment was correct.

Dr. Dickholtz, Sr. describes the adjustment as equivalent to major surgery done on the body. Recovery time of a month is necessary before experiencing benefits. In my case my heart palpitations, tachycardia and irregular beats subsided immediately.

Follow-up visits include periodic checks to make sure the adjustment is holding.

Within a month of being adjusted I began to feel my neck, shoulder and back muscles loosen. Many aching, arthritic type pains, severe CFIDS-type headaches and the beet-red color in my face and neck subsided.

The ideal is to have the first adjustment be the only one needed, which many of his patients have experienced. My adjustment’s average holding time is three to four months.

The initial adjustment held four months before I hit my head, knocking my alignment out of place. Not totally believing the chiropractic treatment was helping I waited until my next scheduled appointment, two months later. At the time I didn’t realize that my NMOT symptoms along with exacerbated CFIDS symptoms begin almost immediately after my alignment was no longer holding.

Also during the two months that my adjustment was out from December 2000 to February 2001, after having worked three and a half years part time, I began to experience exacerbated CFIDS symptoms. The increased fatigue, inability to concentrate, increased tremors, and a heart rate over 140 when standing, along with fevers and the inability to perform simple daily tasks, resulted in my third total disability. However, within a week of having my neck readjusted, my heart rate dropped under 100 when standing. When my adjustment is holding, I experience great relief even though I am still disabled.

Dealing with CFIDS requires patience, persistence, stamina and a hope in Heaven to complete the journey well. How glad I am that I found a NUCCA Doctor, even though it has not provided the ultimate cure. It has provided restoration of new life to my body and a lessening of many CFIDS related symptoms, along with a continued hope for further healing. When my chiropractic adjustment is holding, the day-to-day pain and difficulties with CFIDS are much more manageable and less painful, allowing me to have a focus on something more enjoyable than my severe suffering.

Middle-Aged Raynaud’s


While my sister and my mother have had primary Raynaud’s for years, I experienced my first symptoms last winter, at age 47. This winter, I’ve had them almost daily — involving most of my fingers, episodes easily lasting over an hour if I can’t rewarm them in warm water (the only method which works). Since it seems like it is important to rule out Raynaud’s as a symptom of an underlying condition, I just met with a rheumatologist. In addition to noting my unusually late onset, the physician also noted that my nail fold capillaries did not “look as they were supposed to look” when examined under magnification and ordered additional antibody studies (the initial set were negative). If these results are also negative, is the appearance of my nail capillaries sufficiently relevant to ruling out an underlying condition that I should get an additional physician’s opinion?
A.N., New England


Dr. Fredrick Wigley responds:

Studies have found that patients with definite Raynaud’s phenomenon and abnormal capillaries (there is a specific pattern of changes that are seen) have an increased risk of developing a secondary underlying rheumatic disease. This usually occurs within about two years from onset of symptoms, and it occurs in about 20 to 30 percent of patients who present like this without other clinical clues.

If, in addition to the typical nailfold changes, there is also a specific autoantibody, then the risk of secondary disease increases. In one study of patients who had nailfold changes as well as an autoantibody characteristic of scleroderma patients, about 75 percent developed signs of scleroderma in the follow-up years.

Numbness in the Fingers


I’ve been suffering from cold hands and feet for as long as I remember. My son has the same problem, and to him the worst times were when he was pitching in high school and his grip on the ball did not have any feel to it.

For me, I try and avoid shaking hands and always have a response statement ready when I do (in case the other person comments). The impacted finger(s) also lose their feeling and become numb. Hot water takes a long time to make things better. Winters are the worst periods for me, and the frequency of the incidents is relatively higher.
FrozenFingers, SFBayArea


Dr. Fredrick Wigley responds: Thanks for sharing your experience.

Late-Onset Raynaud’s


I had my first Raynaud’s episode at about the same time I started menopause (52). I was driving – don’t remember being cold – but one finger went numb then turned white for several minutes. Since then – five years – my fingers and toes have become very sensitive to cold. Even a cool breeze on the back of my neck can ‘set off’ one or more fingers. I’ve been tested for lupus, RA, scleroderma, etc. – all negative. I worry, though, about the long-term effects.

I have rosacea (related?) and was also a professional writer (damaged fingers, perhaps, but why toes?). My BP is very low (95/55), so Ca blockers are out. My dermatologist suggested I shake my hands to get the blood flow back, but it doesn’t really help. I take fish oil and Vit D. Haven’t tried aspirin yet.

 My mother had Raynaud’s and Hashimoto’s thyroiditis; her sister had Raynaud’s and Lupus; my daughter (24) has had Raynaud’s for about 3 years.

My questions: Is this is a precursor of something worse? Are the episodes damaging and, if so, is the damage cumulative? Could relaxation/biofeedback therapy help? Should I have my daughter checked for any autoimmune conditions?

 Many thanks in advance. Best of luck to the rest of you!
PacNW, Vancouver, Wash.


Dr. Fredrick Wigley responds:

Raynaud’s phenomenon can be a sign of an underlying secondary disease process, and when it starts after age 40 then a good evaluation is needed. Raynaud’s is caused by low blood flow to the fingers and tissues, and in the severe secondary forms it can cause tissue damage. In the primary form it is benign but bothersome. Studies of biofeedback show that this method does not work, but relaxation can help in that anxiety aggravates or triggers Raynaud’s. Primary (benign) Raynaud’s tends to run in families, but so do autoimmune diseases that can be associated with Raynaud’s. It is recommended that an appropriate evaluation is done in every patient with Raynaud’s.

Medications and Raynaud’s


I take a beta-blocker for glaucoma and one of the side effects is Raynaud’s, as stated on the paper insert that comes with the medication. I never had this condition before. It appeared only after I was placed on this particular medication. And I actually didn’t notice the statement in the pamphlet until after I started getting “white fingers”.
John H., N.J.


Dr. Fredrick Wigley responds:

Beta-blockers can cause constriction of finger and skin blood vessels and are reported to aggravate or cause Raynaud’s phenomenon. While some studies suggest that oral beta blockers (I assume you are using topical agents) used for blood pressure control may cause or aggravate Raynaud’s, other specific studies suggest that this is not true and that the effect of beta blockers is mild; and importantly, the newer agents, so-called selective beta blockers, are no more likely to aggravate or cause Raynaud’s. Still, the warning is placed in drug inserts and needs to be considered as one possible cause of symptoms. But it is important to have the condition fully evaluated by a doctor to make sure there is not another cause for the Raynaud’s.

Blood Pressure Drugs and Raynaud’s


I am a 65-year-old female currently taking Diovan, a multivitamin, aspirin and fish oil and have experienced Raynaud’s symptoms (I think) for a year. At first it was only one finger…my pinky, and only occasionally. Last week both hands became mottled, white, numb. It took several minutes under warm water to return to normal, except for my ring finger on one hand. It took several minutes longer with my hand in gloves tucked under my arm. This event had been preceded by a chill while outside in low 60 degree weather with a wind chill. What should I be asking my primary M.D.? I have my annual physical next week. Thank you
PAA, Albuquerque


Dr. Fredrick Wigley responds:

While Diovan is a good blood pressure medication, it does not help Raynaud’s much. Given the late age of onset of Raynaud’s and the intensity of the events, you should have a complete medical evaluation to determine why this is happening, with a focus on the status of the larger blood vessels in your arms. The doctor should then be better able to explain why this is happening and plan some appropriate intervention.

Raynaud’s and Surgery Complications?

My late husband died about 4 yrs ago after cardiac bypass surgery. He had a history of mild Raynaud’s and also psoriasis. During the week that he lived after the operation, he showed evidence of circulation impairment in multiple organs: renal failure, bowel necrosis, and impaired circulation of hands and feet (which were dark purple — the doctors said that if he had lived, he might have had to have amputation of one or both lower legs/feet, and his hands looked equally bad). Autopsy showed infarction of the kidneys and large bowel. The cause of his death was sepsis secondary to the bowel infarction.

Is Raynaud’s syndrome associated with increased risk of post-op circulatory problems and organ infarction?

Is there anything that doctors and patients can do to lessen or manage this risk?
Katherine, Northern California


Dr. Fredrick Wigley responds:

Raynaud’s phenomenon alone is not associated with the events you describe. A secondary disease associated with Raynaud’s might increase the risk of vascular problems. The main way to prevent problems is to clearly identify the cause of the Raynaud’s and make sure that Raynaud’s and any secondary disease process has ideal management.

Treating Raynaud’s


What is the right way to pronounce “Raynaud’s”?

Isn’t it better to immerse one’s hands in warm, rather than hot, water after an attack?

I am on Nifedical XL, and it reduces my symptoms, but I believe it raises my heart rate. What is my next best medication option?

Is it true that if your appendages hurt when the blood vessels spasm while recovering from an attack, you’re probably going to develop a rheumatological disease?
Heron, Chicago


Dr. Fredrick Wigley responds:

The correct pronunciation is: “ray nodes.”

Warm water should work, and hot water may injure the skin if too hot.

There are a variety of vasodilators that can be used, and the exact one for a patient needs to be customized by a full understanding of the individual’s health situation.

The presence of pain suggests that the attacks are associated with ischemia, or very low blood flow, and thus low oxygen. Pain is usually seen in patients with a secondary cause for the Raynaud’s. Most patients with primary Raynaud’s (the benign form) do not have painful events, but some state that on recovery the skin blush is uncomfortable.

Medications for Raynaud’s


Hello, I am 35 and have Raynaud’s (but thankfully, no other autoimmune problems). This winter I was prescribed Norvasc because my toes were so painful (and ugly – turning black on parts of several toes).

My question is this: if I choose to take the Norvasc only during the colder weather, do I need to taper off and on it? I found that I was feeling a bit drugged and generally under the weather while taking the medication, and as soon as the weather warmed up I stopped cold turkey (or cold toes, as the case may be…)
susanna, westchester county


Dr. Fredrick Wigley responds:

Whne amlodipine (brand name Norvasc, a calcium channel blocker) is used for Raynaud’s phenomenon alone (an off-label, or non-F.D.A. approved use), it can be stopped quickly. Of course, if the medication is used for another reason like hypertension, then one needs to discuss options for discontinuing it with a doctor. Often, patients with mild Raynaud’s or low blood pressure will stop this drug (or another calcium channel blocker) when used for Raynaud’s alone during the warm summer months or if side effects occur.

Diabetes: Protect Your Feet and Legs

Here are some of the foot and leg problems related to diabetes that can lead to amputation if they are not treated promptly:

  • Blocked blood vessels can occur in your leg when there is poor circulation from diabetes. Vascular surgery may be needed to unblock them and restore circulation, but it is not always successful.
  • Bunions and hammertoes may be caused by nerve damage. If they aren’t treated, more ulcers (sores) can develop.
  • Calluses and corns can result from ill-fitting shoes. Treat these early or they may become ulcers.
  • Charcot foot is a foot deformity caused by neuropathy. An absence of pain could lead you to continue to walk on a broken bone, and then complications can develop.
  • Cracked, dried skin might not seem like a big deal, but the cracks can turn into ulcers that won’t heal.
  • Nail problems such as ingrown toenails or fungal infections can also turn into ulcers.
  • Patients with diabetes have a higher prevalence of bone fractures, which includes (but may not be limited to) poor bone quality, neuropathy, recurrent hypoglycemia, and medications like thiazolidinediones (TDZs).

13 Steps to Prevent Amputation

Fortunately, the National Institute of Diabetes and Digestive and Kidney Diseases reports that as many as half of all amputations related to these foot and leg complications can be prevented if the problems are caught early.

“Many measures can significantly reduce the risk of ulcer formation, including having properly fitted shoes, doing routine foot checks, not walking barefoot, and stopping smoking,” says Tan. “Properly fitted shoes and moisture-absorbing socks are important to prevent foot injury, particularly with diabetic neuropathy when one may not feel or notice an injury.”

Here is a list of the most important things you can do to avoid amputation.

1. Quit smoking. The American Diabetes Association points out that if you’re a smoker, quitting is the first and best way to prevent an amputation. Smoking decreases the blood flow in the small blood vessels of your legs and feet, making it difficult for wounds to heal.

“Having diabetes and smoking creates an especially high-risk scenario for amputation,” says Matt Petersen, the managing director of medical information and professional engagement at the American Diabetes Association. “In addition to careful management of diabetes with the support of a healthcare provider, smoking cessation is the most direct way to decrease the risk of amputation.”

According to Dr. Tan, stopping smoking is one of the most important measures a diabetes patient can take to protect her health. “Smokers are 30 to 40 percent more likely to develop type 2 diabetes compared with nonsmokers, and the more one smokes, the higher the risk,” says Tan. “Smoking makes arteries harden faster, so circulation becomes worse. High blood pressure and cholesterol are also worsened by smoking, and all of this contributes to poor blood flow and increased cardiovascular risk.”

2. Examine your feet every day. Check for anything out of the ordinary, from cuts and redness to a change in nail color. Even a loss of hair on your toes should be noted. You should also pay attention to the color of your feet and toes. If they turn purple, red, or pink, especially when you are sitting with your legs hanging free, you may have poor circulation.

3. If you discover any swelling, redness, pain, tingling, or numbness, call your doctor. Any pain in your legs after a little activity or at night can be a sign of a blocked artery — call your doctor immediately.

4. Be sure your doctor examines your feet at least once a year or whenever you notice a problem.

5. Carefully wash your feet in lukewarm water daily. Use a soft towel to dry them, including between the toes. Use lotion or cream to soften callused areas. If your feet perspire, use a nonmedicated powder to keep them dry and prevent skin breakdown.

6. Don’t use alcohol, hydrogen peroxide, astringent, or iodine on your feet.

7. See a professional for nail clipping, especially if you have any problems with your feet, such as numbness or hard nails.

8. Don’t treat your feet with over-the-counter callus and corn remedies, and don’t trim those growths yourself.

9. Keep the floor at home or work clutter free to prevent accidents.

10. Look at your socks for blood spots or other fluids. White socks are the best choice, especially if you need to keep careful watch of any wounds or sores that have already developed.

11. Select comfortable, sturdy shoes that fit right. Wear new shoes for just an hour or two at a time to break them in so that you won’t develop sore spots.

12. Before putting on your shoes, check them for little stones, tears, or lumpy spots that could irritate your feet.

13. Going barefoot can leave your feet vulnerable to cuts, puncture wounds, and splinters, so it’s probably a good idea to wear shoes unless you’re on very familiar ground.

In summary, try to avoid anything that can hurt your feet: socks that are too tight or have irritating seams; hot water, heating pads, and electric blankets that might burn a numb area of skin without your being aware of it.

Take these preventive steps — and be vigilant about them — and you’ll have an excellent chance of avoiding many of the diabetes complications that can lead to amputation.

How to Avoid Amputations if You Have Diabetes

About a year ago, Dr. Armstrong treated a 59-year-old man with type 2 diabetes who had been working out at a local health club; 12 hours later, he discovered a screw from a piece of gym equipment lodged in his foot.

Check your feet daily
“The single most important thing that a person with diabetes can do to prevent a problem is to look at their feet every day, just as they comb their hair or brush their teeth,” says Dr. Armstrong. You can use a mirror to examine your feet or have a family member check your feet for you.

An increase in the temperature of your foot, which can be detected with a special infrared thermometer, can be an early sign of trouble. “The foot will get hot before the skin breaks down,” says Dr. Armstrong.

In a study published in 2007 of 225 patients, which was conducted by Dr. Armstrong and colleagues, half of the patients checked the temperature in six places on each foot twice daily and half examined their feet visually. If there was more than four degrees’ difference between the left foot, the thermometer-using patients contacted their doctor.

At the end of the 18-month study, about 5% of patients who used the thermometer developed a foot ulcer compared to 12% of patients who did not. (Dr. Armstrong owns stock in the themometer manufacturer, Xilas Medical, and is a former consultant for the company.)

Other ways to prevent foot problems
Here are more tips on preventing foot problems from the National Diabetes Education Program.

  • Quit smoking if you’re a smoker. Smoking is considered a likely factor in diabetic foot disease.
  • Be super-vigilant about your controlling your blood sugar. According to results of the United Kingdom Prospective Diabetes Study, people with type 2 diabetes who lower their blood glucose through intensive therapy are at reduced risk for neuropathy.
  • Choose shoes carefully.
  • Cut your toenails carefully or have someone else do it if you already have numbness.


Dear Editor:

Blue toe syndrome (BTS) is often described as painful digits with blue or purple discoloration without direct trauma1. Also it can lead to the amputation of toes and feet and be life threatening. Atheromatous embolism caused by vascular wall injuries from invasive percutaneous procedures or from anticoagulant or fibrinolytic therapy is reported as a common cause of BTS2. However, other causes of decreased blood flow are thrombosis, vasoconstrictive disorders, infectious and noninfectious inflammation, and other vascular obstruction2. The conditions which lead to thrombotic state such as disseminated intravascular coagulation (DIC) can also give rise to BTS. Herein, we report a rare case of BTS that occurred as an early sign of DIC.

In our institute, a 69-year-old male complained of non-palpable bluish discoloration on both feet after he was admitted to the ICU ward due to pneumonia (Fig. 1). The physical examination demonstrates symmetric color change with petechiae that had lasted 1 month. The toes felt cold, and the sensation of toes was uncheckable because of his semi-coma status. Also the patient has been treated for pneumonia with history of diabetes mellitus, hypertension, and cerebral infarct. On histological examination from his foot, ischemic necrosis of epidermis and tons of red blood cell extravasation were found (Fig. 2A, B). Also, there were eosinophilic fibrinoid thrombi in the medium- sized vessels and leukocytoclasis (Fig. 2C). The laboratory results were as follows: white blood cell 28,470/mm3, hemoglobin 9.4 g/dl, platelet 37,000/mm3, prothrombin time/activated partial thromboplastin time 18.4/91.7 s, fibrinogen 71 mg/dl, D-dimer 3.75 mg/L. Hence, we could confirm that the causative disease might be DIC. After then, we obtained the result of multi drug resistant acinetobacter baumannii bacteremia from the blood culture. Gram stain and bacterial culture of the skin tissue were not conducted. We concluded that DIC resulted from severe infectious bacteremia. Henceforward, the patient was treated with vancomycin and conservative care for DIC. However, the patient died after 1 month. The possibility of purpura fulminans was ruled out because the patient’s lesion was limited to the toes.

Blue to purple discoloration with petechiae on the right foot. (A) Scanning view (H&E, ×40). (B) Ischemic necrosis of epidermis, and red blood cell extravasation (H&E, ×200). (C) Eosinophilic fibrinoid thrombi in medium-sized vessels (arrow) and leukocytoslasis (H&E, ×400).

Some conditions that might lead to the slow blood flow or vascular damage that causes BTS are: 1) decreased arterial perfusion, 2) impaired venous outflow, and 3) abnormal circulating blood2,3. Our case corresponds with decreased arterial flow, by thrombosis, not by embolism2. Histologically intravascular fibrin thrombi proved this thrombosis in our case. Besides, this hypercoagulable states can developed diverse cutaneous findings other than BTS2. But if the patient’s underlying disease is unclear, we should commit several kinds of work-up such as complete blood count, blood chemistry, urinalysis, culture, antibody, X-ray as well as computerized tomography angio2.

DIC is a process which describes widespread abnormal activation of the clotting pathway and generation of excess thrombin2,4. It results in intravascular fibrin formation and thrombotic occlusion of small and larger vessels. Although DIC has to be managed in internal medicine, there are some needs for dermatologists to know it. Because most initial signs of DIC begin with cutaneous findings like BTS, petechiae, purpura fulminans, peripheral gangrene5. In conclusion, we report an instructive case of BTS as an early sign of DIC.

Blue Toe Syndrome

Written By: Chloe Wilson – BSc(Hons) Physiotherapy
Reviewed By: FPE Medical Review Board

Blue toe syndrome, also known as Trash Foot or Purple Toe Syndrome, is caused by a blockage of the small blood vessels in the foot that reduces the flow of blood and oxygen to the tissues. It usually develops due to a problem higher up the blood stream such as an aneurysm or atherosclerosis.

The condition develops suddenly and can be really painful. It may affect one toe or a number of toes. The toes turn a blue colour due to the lack of oxygen and if left untreated the skin can ulcerate, tissues begin to die and eventually gangrene sets in. If this happens, amputation may be necessary so early treatment is essential.

Here we will look at the common symptoms, causes, diagnosis and treatment options for blue toe syndrome. For other causes of toe pain, visit the toe pain diagnosis section.

Symptoms of Blue Toe Syndrome

The most common symptoms of Blue Toe Syndrome are:

  • Intense Pain: High levels of pain. This tends to be in the foot and can sometimes also occur further up the leg
  • Livedo Reticuarlis: this is a lace-like bluey purplish discoloration of the skin
  • Foot Pulses: The peripheral foot pulses are usually still palpable
  • Age: The syndrome usually affects people over the age of fifty

Trash Foot symptoms usually develop suddenly and rapidly. They may affect one or more toes but ar usually confined to one foot.

What Causes Purple Toe Syndrome

Blue or purple toe syndrome develops when there is a blockage in the small blood vessels of the foot. This blockage reduces the blood flow to the toes, known as ischaemia. The blockage is usually caused by either cholesterol crystals or a lump of plaque getting stuck.

Plaque deposits are a waxy substance made up of things like fatty acids, cholesterol and calcium. They build up on the inner lining of arterial walls over a number of years. Sometimes, small bits of plaque break off (known as embolisation) and then travel round the body in the blood stream.

In blue toe syndrome, the plaque tends to break off from blood vessels near the groin and abdomen (known as the abdominal aorta-iliac-femoral arterial system). It travels through the blood stream and gets lodged in the small blood vessels of the foot.

This limits the flow of oxygen and glucose to the toes, both of which are needed to keep cells alive. The result is destruction and death of the surrounding tissues. The toes start to turn a bluey purple colour (known as cyanosis) due to the lack of oxygen, hence the name blue toe syndrome.

Trash foot is most common in men over the age of 40. Embolization and resultant blockage of the blood vessels can occur for a number of reasons:

  • Spontaneously: a piece of plaque breaks off with no specific cause
  • Surgical Procedure: most commonly vascular surgery or angiography (where a small catheter is passed through the blood vessels to examine the arteries)
  • Medical Treatment: Anti-coagulants (blood thinners such as warfarin) or thrombolytic treatment (to break up large blood clots)

Diagnosing Trash Foot

Ultrasound scans and CT angiograms are the diagnostic tools of choice with purple toe syndrome.

Blue toe syndrome can be difficult to diagnosis. Usually, the most common sign of a blockage in the blood vessels is the loss of foot pulses but in this case, they are usually unaffected.

Diagnosis of Blue Toe Syndrome also concentrates on finding the source of the problem i.e. where the embolus blockage came from in the first place. Usually there will be a problem further up the arterial tree in one of the proximal blood vessels such as an aneurysm (balloon-like bulge filled with blood in the wall of a blood vessel) or plaque deposits (known as atherosclerosis).

How Do You Treat Blue Toe Syndrome?

Once the underlying cause of blue foot syndrome has been found, it can be treated by:

  • Stenting: this is where a mesh tube is inserted into a blood vessel to hold it open and prevent restriction of blood flow
  • Bypass Surgery: where blood flow is diverted around major arteries that are narrow or partially blocked. A healthy blood vessel is taken from another part of the body and attached above and below the affected area so that the blood flow diverts around the blockage
  • Anti-coagulants and anti-platelet therapy: These can help in the short time but are associated with a high recurrence rate of blue toe syndrome

If left untreated, gangrene can set it. Gangrene is a serious condition where a lack of blood supply causes the tissue to die. Early treatment involves debridement (surgical removal of the dead tissue) and antibiotics to treat infection. If allowed to progress, amputation of the affected body part may be required.

Your Questions Answered

Is Blue Toe Syndrome An Emergency? Blue toes on their own are not a medical emergency, but if you have the classic symptoms of Blue Toe Syndrome e.g. your toes turn blue suddenly for no obvious reason and are extremely painful, there is a good chance the blood flow to the foot may be affected which would require immediate medical attention.

Is Blue Toe Syndrome Dangerous? If the blood flow to the foot is reduced, then tissues can quickly begin to die and gangrene can set in. If blue toe syndrome is left untreated long term, amputation of the toes or foot may be required so prompt treatment is essential.

What Can Cause Blue Toes? Anything which affects the blood flow to the feet can cause discoloration of the toes due to an insufficient supply of blood and oxygen to the tissues. This is known as peripheral cyanosis.

What Else Could It Be?

Trash foot is not the only cause of pain and discoloration of the skin. Another common cause is Raynaud’s Disease, a condition where the blood vessels spasm, limiting flow to the fingers and toes. Treatment here is usually with medication, avoiding the cold by wearing gloves and relaxation techniques

If blue toe syndrome is not sounding quite like your problem, visit the toe pain diagnosis section for help working out what may be causing your pain.

  1. Foot Pain Guide
  2. Common Foot Problems
  3. Blue Toe Syndrome

Page Last Updated: 2019-11-12
Next Review Due: 2021-11-12

Causes of cold feet

Updated: September 16, 2019Published: July, 2013

Q. My feet are always cold, especially when I go to bed. Could I have a problem with my circulation?

A. Two of the most common causes of cold feet are decreased circulation in the extremities or a problem with nerve sensation. One cause of decreased circulation is atherosclerosis, where arteries are narrowed by fatty deposits and impede blood flow in the limbs. As a result, your feet may appear blue or purple when you are sitting, and pale or white when you are lying down. You may feel pain in your calves when you walk. Your doctor can usually detect this condition (peripheral artery disease) by checking the pulse in your legs.

A different circulation problem arises when small blood vessels constrict to conserve heat in the body. People who have less body fat (and therefore less insulation) need to conserve more heat, so the feet become cold to keep the internal organs warm. In Raynaud’s syndrome, the small blood vessels overcompensate for cold temperatures. This may make the feet feel cold and appear blue and then white. In response to warm temperatures, the feet then turn red. Some medications, including beta blockers, can mimic this response.

Nerve damage, known as neuropathy, can also cause cold feet. In this case, the person senses a cold sensation because the nerves that detect temperature are not working correctly. The feet do not feel cold to the touch, although the person may feel numbness or a pins-and-needles sensation.

Finally, for some people, cold feet are a normal response of the body. Some researchers believe that having cold feet is an inherited trait. Since there’s no medical cause, warm socks are the solution!

— William Kormos, M.D.
Former Editor in Chief, Harvard Men’s Health Watch

Image: Bymandesigns | Dreamstime.com

As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Blue toe syndrome

What is blue toe syndrome?

Blue toe syndrome, also known as occlusive vasculopathy, is a form of acute digital ischaemia in which one or more toes become a blue or violet colour. There may also be scattered areas of petechiae or cyanosis of the soles of the feet.

Blue toe syndrome is associated with small vessel occlusion and can occur without obvious preceding trauma or disorders that produce generalised cyanosis, such as hypoxaemia or methaemoglobinaemia . It most often presents in an older man who has undergone a vascular procedure.

What causes blue toe syndrome?

The characteristic blue discolouration and pain in blue toe syndrome are caused by impaired blood flow to the tissue resulting in ischaemia. The impairment of blood flow is due to one or more of the following factors:

  • Decreased arterial flow
  • Impaired venous outflow
  • Abnormalities in circulating blood.

These are not mutually exclusive. For example, abnormal circulating blood can induce vasculitis and subsequent thrombosis of the arterioles and capillaries supplying blood to the toes, resulting in a decreased arterial flow.

The causes of blue toe syndrome

Decreased arterial flow

The blockage or narrowing of arteries by the small clots that lead to blue toe syndrome can result from a number of different conditions.


  • Cholesterol emboli are cholesterol fragments or fibrin–platelet material released into the bloodstream from ulcerated arteriosclerotic plaques in the large arteries (eg, the aorta, and the iliac and femoral arteries) and are the most common cause of blue toe syndrome. Risk factors include smoking, hypertension, elevated cholesterol levels, and a recent angiogram or vascular surgery.
  • Embolisation (formation of an embolus, a floating mass in the bloodstream that can clog the arteries) can also occur spontaneously .
  • Emboli may originate from a cardiac tumour or from vegetations (clots or growths made of fibrin and blood platelets) from a cardiac myxoma or endocarditis (septic emboli). It is rare that an embolus will develop without any apparent cardiovascular risk factors or a precipitating event .


  • Thrombosis can form in the small vessels of the feet.
  • It can result from the antiphospholipid syndrome, thromboangiitis obliterans, malignancy, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and warfarin-induced skin necrosis .

Vasoconstrictive disorders

  • Narrowing of blood vessels in the feet can be a result of muscular wall contraction.
  • In Raynaud disease, vasoconstriction tends to affect multiple fingers more severely than the toes.
  • Causes include medication-induced vasoconstriction (eg, a beta-blocker or illicit drug such as cocaine) and/or acrocyanosis .

Infectious and non-infectious inflammation

Occlusion can also be due to syphilis, pyogenic infection (sepsis), Behçet disease, and other forms of vasculitis .

Other causes of vascular obstruction

Narrowed blood vessels can be due to calcific vasculopathy (calciphylaxis .

Impaired venous outflow

Abnormal venous drainage associated with extensive venous thrombosis results in phlegmasia cerulea dolens (a painful form of blue toe syndrome associated with leg oedema). Many patients have predisposing factors for venous thrombosis, including:

  • Immobility
  • Clotting disorders
  • Pregnancy
  • Previous leg trauma
  • Malignancy .

Abnormalities in circulating blood

Blue toe syndrome can be due to abnormal blood constituents. See the DermNet NZ page on Skin conditions of haematological disorders.

  • Platelet plugging
  • Myeloproliferative disorders (eg, polycythaemia rubra vera and essential thrombocythaemia)
  • Paraproteinaemia (which causes hyperviscosity)
  • Cryoglobulinaemia
  • Cryofibrinogenaemia
  • Cold agglutinin anaemia
  • Paroxysmal nocturnal haemoglobinuria

What are the clinical features of blue toe syndrome?

The clinical features of blue toe syndrome can range from an isolated blue and painful toe to a diffuse multi-organ system disease that can mimic other systemic illnesses. Any organ or tissue can be affected, although the skin and skeletal muscles of the lower extremities are almost always involved .

Cutaneous abnormalities are usually one of the earliest symptoms; most commonly, blue or purple discolouration of the affected toes . Discolouration may affect one foot or both, depending on the underlying pathophysiology. It is often painful and may be associated with claudication.

In a series of 223 patients with cholesterol embolisation, the most frequent cutaneous findings were:

Livedo reticularis may be non-blanching or blanching when the discolouration disappears with pressure and/or fades with leg elevation . Blanching occurs in the first stages of blue toe syndrome, as the sluggish flow of desaturated blood results in the temporary obstruction of blood flow .

  • Pain in the affected blue toe or toes is usually of acute onset and occurs at rest. The non-discoloured areas of the foot and distal limb can also be painful .
  • The affected toes are cold compared to unaffected parts of the foot, which are warmer and appear well-perfused . Foot pulses may be normal.
  • Peripheral foot pulses may be palpable if an occlusion occurs in the small arteries and arterioles rather than in large palpable arteries .

What are the complications of blue toe syndrome?

Mild forms of blue toe syndrome have a good prognosis and subside without sequelae . However, cholesterol fragments blocking blood vessels to other organs can lead to multi-organ disorder . Involvement of the kidneys has a poor prognosis.

Patients with untreated blue toe syndrome from embolisation can suffer from further emboli in the subsequent weeks, resulting in substantial occlusion and the ischaemic loss of digits, the forefoot, and the limb (dry gangrene), necessitating amputation .

How is blue toe syndrome diagnosed?

Blue toe syndrome is a clinical diagnosis based on patient history and findings on examination. It is important to determine the underlying cause of blue toe syndrome to guide treatment . There are usually clues from the clinical assessment, but to confirm the diagnosis, investigation in the form of laboratory blood works, tissue biopsies, and radiological imaging is required.

History and examination should focus on:

  • Hypertension or other risk factors for hypercholesterolaemia and atherosclerotic diseases
  • Fever (indicating cholesterol emboli, infective endocarditis, myxoma, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation)
  • Cardiac murmur (infective endocarditis and atrial myxoma)
  • Livedo reticularis (cholesterol emboli, myxoma, antiphospholipid syndrome, hyperviscosity syndrome, cryofibrinogenaemia, cryoglobulinaemia, and calciphylaxis)
  • Extensive oedema in the ipsilateral leg (phlegmasia cerulean dolens)
  • Hollenhorst plaques (cholesterol emboli) noted on retinal examination
  • Dilated veins, haemorrhages, and exudates in retinal examination (hyperviscosity syndrome) .

A full blood count including a white cell differential, erythrocyte sedimentation rate, and C-reactive protein may indicate elevated inflammatory markers. These are often non-specific in blue toe syndrome and can occur with cholesterol emboli as well as numerous other inflammatory driven processes. The blood count and peripheral blood film can help diagnose bone marrow or autoimmune diseases. Liver and renal functions should also be checked.

Other more specific blood tests may include:

  • Coagulation tests for disseminated intravascular coagulation
  • Antinuclear antibodies
  • Antiphospholipid antibodies
  • Blood cultures (for suspected septic emboli)
  • Haemolysis screen
  • Cold agglutinins
  • Cryofibrinogen level
  • Cryoglobulin level
  • Serum and urine protein electrophoresis and immunofixation
  • Hepatitis C (for suspected cryoglobulinaemia)
  • Syphilis serology .

Imaging may include:

  • A chest radiograph and/or thoracic and abdominal computed tomography or magnetic resonance imaging to look for any aortic atheroma and underlying cancer in malignancy-associated conditions
  • A peripheral angiogram and a scan of the limb arteries (to locate vessel narrowing, occlusion, and/or determine the source of emboli)
  • Sonography of the abdomen and a venous duplex ultrasound scan to detect deep venous thrombosis
  • An echocardiogram to detect cardiac tumours or vegetations from endocarditis .

A definitive diagnosis is usually made by the histopathological confirmation of a biopsy of the affected skin or other involved tissues . Biopsies in patients with a poor peripheral vascular supply should be performed with caution as poor healing is likely at the sampling site. The histopathological findings for cholesterol emboli show intravascular cholesterol crystals, which may be associated with macrophages, giant cells, and eosinophils .

What is the treatment for blue toe syndrome?

The principles of treatment revolve around addressing the cause of the blue toe syndrome. This is usually in the form of relieving occlusion and restoring arterial or venous vessel continuity .

  • Medical anticoagulation (especially antiplatelet drugs), and surgical endovascular or reconstructive procedures are indicated for emboli and thromboses, to remove the source of the clot, resolve occlusion, and restore blood flow.
  • Haematological treatment may be required when blue toe syndrome is due to hyperviscosity .
  • Supportive and symptomatic treatments of blue toe syndrome include rest, warm conditions, appropriate dressings, and hydration .

Address patient risk factors

Risk factors should be addressed in patients with advanced atherosclerotic disease, including:

  • Smoking cessation
  • Control of hypertension
  • Reduction of serum cholesterol.

Patients with stenotic lesions should be followed up carefully, as the progression of the atheromatous disease will result in a strong likelihood of repetition of the blue toe syndrome .

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *