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Blue Toe Syndrome

Blue Toe Syndrome

What is Blue Toe Syndrome?

Occlusive vasculopathy, often known as blue toe syndrome, is a kind of acute digital ischemia in which one or more toes turn blue or violet in color. Petechiae or cyanosis of the soles of the feet may be present in isolated areas. There may also be scattered areas of petechiae or cyanosis of the soles of the feet.

Blue toe syndrome (BTS) is characterized by painful digits with a blue or purple discoloration that does not occur as a result of direct damage. It can also result in the amputation of toes and feet, which can be fatal.

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Acute digital ischemia manifests itself as blue toe syndrome. This means that happens when the blood supply to the toes is inadequate.

One or more of the following factors can cause a reduction in blood flow:

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

The blood transports oxygen from the lungs to every part of a person’s body. To repair and multiply, each cell requires oxygen. The blood also transports waste products and provides all of the nutrients that cells require.

Inadequate blood supply damages cells and the tissues that they make up. This might cause the tissue to turn blue or purple in color. The condition is known as blue toe syndrome when it affects the toes.

Some people with this condition have just one discolored toe on one foot. Others might have discolored toes on both feet.

Some people will find that the toes go back to their normal color when they put pressure on the skin or when they elevate their foot.

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Blue toe syndrome can cause the following symptoms in addition to blue or purple toes:

  • Moderate or severe forefoot pain
  • Leg muscles pain
  • Ulcers on the feet
  • Nodules or lesions on the feet
  • Bruising

Causes of Blue Toe Syndrome

When a blockage in the small blood vessels in the foot prevents the tissues from receiving enough blood, blue toe syndrome develops. Blue toe syndrome can be caused by a variety of factors.


Cholesterol is a waxy molecule that the body requires to produce hormones, vitamin D, and other digestive aids. The body produces all of the cholesterol it requires, but it is also found in foods such as eggs, beef, and cheese.

When blood cholesterol levels are excessively high, it can combine with other chemicals to produce plaque. When plaque adheres to the artery walls, it narrows them, resulting in atherosclerosis. Plaque can also obstruct the flow of blood through the arteries.


When something blocks a blood vessel, it is called an embolism. Plaque fragments can break out from the arterial walls and move through the bloodstream until they become lodged. Blood clots can do the same thing.

Embolisms can develop spontaneously or as a result of an angiography, vascular surgery, medicine, or renal failure.


An angiogram is a form of medical imaging. Doctors use it to detect and treat blood artery blockages and atherosclerosis.

A needle is inserted into an artery in the groin, and thin tubes called catheters are threaded through the arterial system. While injecting a contrast agent into the bloodstream, the team will take X-ray photographs of the person. This chemical aids in the detection of any obstructions or other difficulties.

The operation can sometimes knock a fragment of plaque off the artery walls, causing blue toe syndrome, according to researchers.

Vascular surgery

Any procedure on the circulatory system is referred to as vascular surgery. The arteries, veins, and lymphatic system are all part of this system.

Embolisms are a possible side effect of vascular surgery. A plaque fragment, blood clot, or other particles might circulate in the bloodstream until it becomes lodged in a blood vessel. Blue toe syndrome can arise when this happens in the foot.

Inflammation caused by infectious and non-infectious agents

Syphilis, pyogenic infection (sepsis), Behçet illness, and various types of vasculitis can all cause occlusion.

Impaired venous outflow

Phlegmasia cerulea dolens is caused by abnormal venous drainage along with severe venous thrombosis (a painful form of blue toe syndrome associated with leg oedema). Predisposing factors for venous thrombosis exist in many people, including:

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

Circulating blood abnormalities

Abnormal blood components can cause blue toe syndrome. These includes:

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


Medicines used to thin the blood or cure blood clots, according to the European Society of Cardiology, can also cause blue toe syndrome. Cocaine and other recreational drugs can potentially cause the condition.

Renal failure

The kidneys play several roles in the human body:

  • Removing waste products from the bloodstream and disposing of them in the urine
  • Ensuring that the blood contains the proper balance of nutrients that cells require, such as sodium, potassium, and calcium
  • Produces hormones that regulate blood pressure and red blood cell production

Renal failure occurs when the kidneys are unable to function normally. According to the European Society of Cardiology, this condition can lead to blue toe syndrome


The clinical diagnosis of blue toe syndrome is based on the patient’s history and examination findings. To guide treatment, it’s essential to figure out what’s causing blue toe syndrome in the first place. The clinical examination usually provides clues, but more investigation in the form of laboratory blood tests, tissue biopsies, and radiographic imaging is required to confirm the diagnosis.

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 complete blood count, which includes a white cell differential, erythrocyte sedimentation rate, and C-reactive protein, can reveal high inflammatory markers. These are common in blue toe syndrome and can be caused by cholesterol emboli or a variety of other inflammatory processes. Bone marrow or autoimmune diseases can be diagnosed using a blood count and peripheral blood film. It’s also a good idea to assess your liver and kidney functions.

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

Histopathological confirmation of a biopsy of the affected skin or other relevant tissues is usually used to make a definitive diagnosis. Biopsies should be performed with caution in individuals with a low peripheral vascular supply because poor recovery is possible at the sampling site. Intravascular cholesterol crystals are seen in the histological findings of cholesterol emboli, which may be linked with macrophages, large cells, and eosinophils.


The goal of treatment is to get the blood circulating again in the toes. Doctors may recommend one or more of the following options, depending on the cause of the problem.

  • Stenting

A vascular surgeon places a stent, or mesh tube, in the damaged blood vessel. This keeps the vessel open, allowing blood to flow freely.

  • Bypass surgery

A vascular surgeon makes a bypass around the obstruction by using a healthy blood vessel from another part of the body.

  • Doctors usually also advise people to:
    • Rest
    • Keep warm
    • Drink plenty of fluids


The tissues in the foot may die permanently if surgeons do not restore blood flow. This is referred to as gangrene by doctors. Signs and symptoms are:

  • Blue or black skin — appearance can vary with darker or lighter skin
  • Pain
  • Numbness
  • Sores with a foul-smelling discharge

Although gangrene is a dangerous condition, it can usually be treated with surgery, antibiotics, and oxygen therapy. Doctors may need to amputate the damaged toes in severe cases.

When should you see a doctor?

Anyone who suspects they have blue toe syndrome should seek medical help as soon as possible. Those who fear they have gangrene should seek medical help immediately.


Blue toe syndrome is normally easy to treat in mild cases, but more severe cases might lead to various complications.

The outlook is usually determined by the underlying problem. Renal failure, for example, might have long-term consequences. Plaque fragments can also block other blood vessels, causing problems in other sections of the body, including the organs.

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The purpose of prevention is to keep the heart and vascular system as healthy as possible. This includes the following:

  • Avoiding smoking cigarettes 
  • Keeping active
  • Maintaining a moderate weight according to the BMI (Body Mass Index)
  • Eating a balanced diet and avoiding foods that are high in cholesterol
  • Avoid alcohol intake


Blue toe syndrome is caused by a lack of blood circulation to the feet. When too much plaque adheres to the inside of arteries, or when a plaque fragment or a blood clot stops a blood vessel in the foot, this can happen.

Blue toe syndrome can be caused by angiography, vascular surgery, certain medicines, or renal failure.

Doctors must restore the blood circulation to the feet in order to resolve the condition. This condition can progress to gangrene or even amputation if not treated properly.

The easiest approach to avoid blue toe syndrome is to have a healthy cardiovascular system.


  • Is blue toe syndrome an emergency?

Yes, Blue Toe Syndrome is an emergency. Immediate measures should be taken to restore blood flow to the toes. Otherwise, the toe will be necrosed. 

  • How do you treat purple toe syndrome?

Blue toe syndrome is treated by Stenting or Bypass Surgery. Other antiplatelet medications and lifestyle modifications are also done. 

  • What causes blue or purple toes?

Due to reduced blood supply to the affected toes. Blue or Purple toes occurs in Blue Toe Syndrome

  • What can be done for blue toe syndrome?

Immediately consult a vascular surgeon and do revascularization by stenting or bypass. 

  • What does poor circulation in your feet look like?

It will be cold and bluish color.  

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