What is Cold Urticaria?

Cold urticaria, or cold-induced urticaria, is an allergic reaction that affects the skin when it is exposed to something cold, such as cold water, weather, or ice. The cold temperature triggers immune system cells in the skin – called mast cells – to react and release histamine and other chemicals. Commonly a red, itchy rash appears within a few minutes of the cold exposure.

Cold urticaria is quite rare although the exact number of people who have the condition is not known. In Europe, it’s estimated that about one in every 2,000 people.

What causes cold urticaria?

For most people the cause is unknown – this is referred to as idiopathic. Occasionally it might be triggered by an infection, insect bite, some drugs, or blood cancers.

What are the symptoms?

The number and severity of symptoms vary from person to person. The most common symptom is a red, itchy rash (hives, welts, or wheals) on the area of skin exposed to the cold.

Other symptoms include:

  • Swelling (edema) in the area under the skin exposed to the cold
  • Headache

Symptoms can appear five to 10 minutes after the cold exposure, lasting usually up to a couple of hours. The symptoms can worsen as your skin warms after the cold exposure.

Occasionally people experience a severe, whole-body allergic reaction known as anaphylaxis, which can lead to difficulty breathing, shock, or fainting. This is a medical emergency and urgent treatment is required.

Who is at risk?

Cold urticaria usually develops in early adulthood, but it can affect people of any age. Women are more likely to have it than men.

How is it diagnosed?

If you experience symptoms, you should see your family doctor, who will first ask you about:

  • Your medical history, including if you have any allergies
  • Infections
  • Insect stings
  • Current medications
  • Recent changes in your diet.

Your doctor may rule out or consider certain diagnoses based on your answers. If they suspect cold urticaria, they may refer you to a specialist or conduct a test themselves.

Diagnosis is a simple procedure called the ‘ice cube test’. Your doctor will place an ice cube on your arm for about five minutes then remove it and wait to see if your skin reacts as it warms up. If you have cold urticaria, after a few minutes a red ‘wheal’ will usually flare up and appear where the ice cube was placed.

While this test is fairly reliable, it is not 100% accurate. For example, some people only react to much longer cold exposure; for others, the wheals are delayed and appear a few hours later. Usually, your medical history combined with the ice cube test is enough to give a diagnosis, though.

Some doctors use a specially designed temperature device instead of an ice cube.

Treatment of cold urticaria

The first treatment option is to avoid cold exposure. However, depending on your occupation, lifestyle, or where you live, this may not always be possible.

Avoidance measures are usually combined with drug therapy. The options include:

  • Antihistamines (non-sedating) – these can be purchased over the counter or your doctor may prescribe them. Your doctor may need to gradually increase the dose of your antihistamine to find the right level for you
  • Omalizumab is an asthma drug sometimes used to treat antihistamine-resistant cold urticaria.

If you are at risk of anaphylaxis, your doctor may also prescribe an epinephrine auto-injector for you to carry with you in case of emergency. This is a medical device that you can use to quickly administer a dose of epinephrine (adrenaline) at the first sign of anaphylaxis. The drug will help to slow the allergic reaction, but you must still seek medical attention.

How can I manage my cold urticaria?

Most people rely on lifestyle changes to avoid flare-ups of their condition. However it doesn’t affect everyone in the same way.

It can be helpful to get to know your common triggers and how the condition affects you personally. For example, can you tolerate moderately low temperatures without your skin reacting, or is your temperature threshold quite high?

If you know you’re going to be unavoidably exposed to the cold, consider taking your antihistamine in advance.

As well as taking your medication as prescribed, avoid or take precautions with:

  • Visiting places with low ambient temperature e.g. cellars, ice rinks, supermarkets with refrigerated cabinets, etc.
  • Outdoor leisure activities e.g. swimming, watersports, snowsports, caves, and mountains
  • Household jobs e.g. window cleaning, defrosting the freezer
  • Cold cosmetic procedures
  • Chilled/frozen foods and drinks.

Before any medical or dental procedure or childbirth, tell your healthcare team that you have cold urticaria so they can keep you warm during the procedure.

Will my cold urticaria go away?

Cold-induced urticaria is a chronic condition, lasting more than six months. It usually lasts some years, though about one in three people report that their symptoms go away with five to ten years.

If you think you have cold urticaria, you should speak with a medical professional who can offer you advice.

 

SOURCES

AAAAI 2020. Hives (urticaria) and angioedema overview. American Academy of Allergy, Asthma and Immunology. https://www.aaaai.org/conditions-and-treatments/library/allergy-library/hives-angioedema

British Association of Dermatologists. 2020. Urticaria and angioedema. Patient Information Leaflets. https://www.bad.org.uk/for-the-public/patient-information-leaflets/urticaria-and-angioedema/?showmore=1#.YHg7ruhKhPY

Bernstein JA, Lang DM, Khan DA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133: 1270-7. https://www.jacionline.org/article/S0091-6749(14)00335-2/fulltext

GARD 2020. Genetic and Rare Diseases Information Center. US Department of Health & Human Services. https://rarediseases.info.nih.gov/diseases/6131/cold-urticaria

Kulthanan K, Hunnangkul S, Tuchinda P et al. Treatments of cold urticaria: A systematic review. J Allergy Clin Immunol 2019; 143: 1311-1331. https://www.jacionline.org/article/S0091-6749(19)30209-X/fulltext

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Mayo Clinic. 2019.  Diagnosis & treatment. https://www.mayoclinic.org/diseases-conditions/cold-urticaria/diagnosis-treatment/drc-20371051

Mayo Clinic. 2019.  Symptoms & causes. https://www.mayoclinic.org/diseases-conditions/cold-urticaria/symptoms-causes/syc-20371046

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Zuberbier T, Aberer W, Asero R et al. The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria. Allergy 2018; 73: 1393-1414. https://onlinelibrary.wiley.com/doi/full/10.1111/all.13397