Erythromelalgia: red, hot, burning feet and how to cool them safely

What erythromelalgia is

During a flare the skin turns red and hot and burns, often starting as an itch, sometimes with swelling or sweating. Flares last from minutes to days, and between them the skin may look normal or feel cool. It affects the feet in about 90 percent of people and the hands in about 25 percent, usually on both sides. The visible redness and heat help tell it apart from other causes of burning feet.

What sets it off. Flares are brought on by hot weather, a warm room, exercise, standing, tight shoes, and letting the feet hang down. Alcohol, spicy food, caffeine, stress and dehydration can also trigger flares. They are often worst late in the day or at night.

How common it is. Estimates vary widely, partly because many people are never diagnosed. A Mayo Clinic study in Olmsted County, Minnesota (2009) counted 1.3 new diagnoses per 100,000 people a year, at a median age of 61. A 2013 community study in Dunedin, New Zealand, estimated that 15 in 100,000 people had the symptoms, and only 27 percent of them had a diagnosis.

Primary and secondary erythromelalgia

Primary erythromelalgia has no underlying disease behind it, and most often no cause is found at all. Less often it is inherited: 15 percent of cases come from changes in the SCN9A gene, MedlinePlus Genetics (2016) estimates, though NORD (2023) puts cases that run in families at about 5 percent. The gene helps make Nav1.7, a sodium channel in pain-sensing nerves. The inherited form usually begins in childhood or the teens, sometimes with no family history.

Secondary erythromelalgia comes with another condition and often eases once that is treated. The main links:

• Blood disorders. The classic ones are essential thrombocythemia and polycythemia vera, bone marrow disorders that make too many platelets or red blood cells. Erythromelalgia with these typically improves quickly with aspirin, taken on a clinician’s advice.
• Medicines, including nifedipine and verapamil, two calcium channel blockers, and bromocriptine. Ask the prescriber before stopping anything.
• Small fiber neuropathy, damage to the thin nerves that carry pain and temperature. In a 2017 Mayo Clinic study of 52 people with erythromelalgia, small fiber tests showed at least one abnormality in all but one. Small fiber neuropathy explained.
• Autoimmune diseases. Lupus is named most often; rheumatoid arthritis, systemic sclerosis (scleroderma) and multiple sclerosis are also reported.
• Others reported: diabetes, some infections and cancers, and gout.

How erythromelalgia is diagnosed

There is no single test. A clinician diagnoses it from the pattern of symptoms after ruling out other causes, and a 2024 review puts the average delay at five years.

Erythromelalgia or Raynaud’s?

The two are sometimes called opposites, and they can occur together. More on Raynaud’s and cold feet.

Calcium channel blockers such as nifedipine, which is used for Raynaud’s, can make erythromelalgia worse, so tell every prescriber about both.

Another look-alike. Pain or burning that eases when the leg hangs down and worsens when it is raised points to poor circulation, the reverse of erythromelalgia, and needs prompt care.

Treatment: what helps

There are no evidence-based guidelines, and no single treatment works for everyone. A 2026 review of 25 studies with 591 people rated the evidence for most treatments as low or very low certainty; aspirin, in erythromelalgia linked to bone marrow disorders such as essential thrombocythemia, was the exception, at moderate certainty.

• Avoiding triggers comes first: loose shoes, a cool room, plenty of fluids, less alcohol and spicy food.
• Treating the cause of secondary erythromelalgia, including reviewing any medicine that may be to blame.
• Aspirin, only on a clinician’s advice. The evidence supports it mainly for erythromelalgia with essential thrombocythemia or polycythemia vera, where it is the drug of choice and usually works. Overall it helps less often: in a 2000 Mayo Clinic study, more than half of 57 people said it was not helpful at all. Don’t start daily aspirin yourself; it can cause bleeding in the stomach or brain and is for adults only.
• On the skin: lidocaine patches, capsaicin cream, and compounded amitriptyline–ketamine.
• By mouth: nerve-pain medicines such as gabapentin, pregabalin, venlafaxine and amitriptyline, antihistamines, misoprostol and magnesium. For primary erythromelalgia, the 2026 review found low-certainty evidence of benefit from mexiletine and carbamazepine; mexiletine, a heart-rhythm drug, carries a serious warning about heart risks. How nerve-pain medicines work.
• For severe cases, specialists may use lidocaine through a vein, nerve blocks or epidural infusions. Sympathectomy, surgery on nerves that control blood vessels, is rare and has been reported to set off flares.

Cooling safely: the part that protects your feet

Cooling done the wrong way can cause serious harm. The NHS says: “do not cool down your hands or feet with cold water or use ice, as this can damage your skin.” The Erythromelalgia Association calls cold-water soaks “a dangerous practice that can seriously damage the skin,” and Cleveland Clinic warns that ice baths can make symptoms worse.

Long or repeated soaks can leave skin soft, wrinkled and white (maceration) and open to germs. They can also cause a cold injury called immersion foot, ulcers, infection and, at worst, tissue death and amputation. With numb feet, you won’t feel it happening.

When to get help urgently

• Call 911 for chest pain, trouble breathing or bleeding you can’t stop, or for sudden numbness or weakness in the face, an arm or a leg, especially on one side, sudden confusion or trouble speaking or seeing, sudden loss of balance, or a sudden severe headache: possible heart attack, stroke or serious bleeding. Essential thrombocythemia and polycythemia vera raise the risk of blood clots.
• Go to an emergency department, or call 911, if a foot or leg suddenly turns very painful, pale, cold, or numb and weak: possibly a blocked artery.
• Go to an emergency department, or call 911, if, after icing or a cold soak, the skin is hard and frozen, swollen and without feeling, or blistered: possible frostbite. Don’t rub it or warm it with direct heat.
• Get seen the same day for one red, hot, swollen leg or spreading redness: possibly a blood clot or cellulitis. Call 911 if you also have chest pain, trouble breathing, a very high temperature, confusion or faintness.
• Get seen the same day for a blister, sore or break in the skin that is red, oozing or getting worse, or a patch that turns dark or black, especially after soaking or icing your feet.
• Call or text 988, or chat at 988lifeline.org, if constant pain ever leaves you thinking about ending your life, or in emotional distress. The 988 Suicide & Crisis Lifeline is free, confidential and available 24/7.

Common questions

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