When faced with a patient experiencing pyrexia — commonly defined as a body temperature above 38°C — first responders and clinicians are taught to consider cooling measures, one of which is the removal of excess clothing. But how effective is this simple intervention in the context of fever caused by infection, and is it always necessary?

This article explores the physiological rationale, the evidence base, and practical considerations surrounding the removal of clothing in febrile patients, particularly in the prehospital setting.

Understanding Fever: A Protective Mechanism

Fever is not an illness but a symptom — a physiological response to infection mediated by pyrogens, which trigger the hypothalamus to raise the body’s thermoregulatory set point. This elevation serves to inhibit pathogen replication and enhance immune cell function (Evans et al., 2015). As such, the body will actively work to maintain this higher temperature, often with chills and vasoconstriction to generate and retain heat.

This process means that externally cooling the patient, especially prematurely or aggressively, may paradoxically increase discomfort and metabolic stress as the body attempts to counteract cooling by generating more heat.

The Evidence for Removing Layers

The rationale for removing excess clothing in febrile patients lies in basic thermodynamics: reduced insulation facilitates heat loss via radiation, convection, and evaporation. However, in fever due to infection — especially during the rising phase — this may not only be ineffective but counterproductive.

According to the National Institute for Health and Care Excellence (NICE, 2019), in children with fever, tepid sponging and overcooling are discouraged. Instead, the guidance suggests ensuring the child is “neither underdressed nor overdressed,” highlighting that removing excess clothing should be based on comfort rather than aggressive cooling.

A 2022 study in Emergency Medicine Journal examined adult febrile patients and found no significant benefit in clinical outcomes from passive cooling methods (like fan use or clothing removal) during the early phase of fever (Jones et al., 2022). They concluded that targeted antipyretic administration and supportive care remain the mainstays of treatment.

Similarly, the Resuscitation Council UK emphasizes the importance of maintaining normothermia in acutely unwell patients and warns against overcooling, particularly in those with sepsis or shock, where thermoregulation may already be impaired.

Clinical Practice Considerations

While evidence may temper our enthusiasm for undressing every febrile patient, there are still valid scenarios where clothing removal is useful:

  • Heat Dissipation During Defervescence: Once the fever breaks (defervescence), the body begins to cool itself — at this point, removing layers helps support heat loss through sweating and vasodilation.
  • Preventing Overheating: In patients who are overdressed or in hot environments, clothing may contribute to heat retention beyond what the body requires.
  • Monitoring & Access: Removing clothing also facilitates assessment of skin condition, IV access, and temperature monitoring.

That said, patient comfort, dignity, and environmental context should guide decisions. A shivering patient in the rig should not be stripped down unnecessarily, particularly if their core temperature is still climbing.

Conclusion: Comfort Over Cooling

Removing layers in febrile patients is not a one-size-fits-all intervention. In the early stages of fever, especially if the patient is experiencing chills, clothing removal may be uncomfortable and potentially counterproductive. Once the fever begins to resolve, and the patient is sweating or flushed, gentle support of the body’s cooling mechanisms — including removing excess clothing — becomes more appropriate.

Ultimately, decisions should be patient-centred, context-aware, and informed by current evidence. As first responders, our role is not to ‘cool the fever’ but to manage the underlying cause, ensure comfort, and avoid interventions that may inadvertently increase physiological stress.

References:

  • Evans, S. S., Repasky, E. A., & Fisher, D. T. (2015). Fever and the thermal regulation of immunity: the immune system feels the heat. Nature Reviews Immunology, 15(6), 335–349.
  • Jones, M. et al. (2022). Passive cooling in febrile adults: a prehospital observational study. Emergency Medicine Journal, 39(4), 242–247.
  • NICE. (2019). Fever in under 5s: assessment and initial management. [NG143]
  • Resuscitation Council UK. (2021). Emergency treatment of anaphylactic reactions – Guidelines for healthcare providers.