The cryosphere reacts sensitively to climate change, as evidenced by the widespread retreat of mountain glaciers. Subsurface ice contained in permafrost is similarly affected by climate change, causing persistent impacts on natural and human systems. In contrast to glaciers, permafrost is not observable spatially and therefore its presence and possible changes are frequently overlooked. Correspondingly, little is known about permafrost in the mountains of the Hindu Kush Himalaya (HKH) region, despite permafrost area exceeding that of glaciers in nearly all countries. Based on evidence and insight gained mostly in other permafrost areas globally, this review provides a synopsis on what is known or can be inferred about permafrost in the mountains of the HKH region. Given the extreme nature of the environment concerned, it is to be expected that the diversity of conditions and phenomena encountered in permafrost exceed what has previously been described and investigated. We further argue that climate change in concert with increasing development will bring about diverse permafrost-related impacts on vegetation, water quality, geohazards, and livelihoods. To better anticipate and mitigate these effects, a deepened understanding of high-elevation permafrost in subtropical latitudes as well as the pathways interconnecting environmental changes and human livelihoods are needed.