From the Guidelines
The primary treatment for cold urticaria involves avoiding cold exposure and using antihistamines, with second-generation H1 antihistamines being the first-line treatment. The treatment approach for cold urticaria focuses on relieving symptoms and preventing further reactions. Key considerations include:
- Avoiding cold exposure to prevent triggering reactions
- Using antihistamines to block histamine release that causes hives and itching
- Considering second-generation H1 antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) as the first-line treatment
- Increasing dosages up to four times the standard dose under medical supervision for more severe cases
- Using epinephrine auto-injectors (like EpiPen 0.3mg or 0.15mg for children) during acute reactions for severe symptoms such as breathing difficulties or significant swelling, as suggested by guidelines for managing urticaria 1 For patients with persistent symptoms despite antihistamine use, omalizumab (Xolair) injections might be prescribed by specialists. Additionally, gradual cold exposure therapy (cold hardening) may help some patients develop tolerance, but should only be attempted under medical supervision. It is essential to note that oral corticosteroids, as discussed in guidelines for evaluation and management of urticaria 1, should be restricted to short courses for severe acute urticaria or angio-oedema affecting the mouth, and are not the primary treatment for cold urticaria. Patients should carry their emergency medication at all times and wear medical alert identification to ensure prompt treatment in case of severe reactions.
From the FDA Drug Label
Cold urticaria Amelioration of allergic reactions to blood or plasma. Cold urticaria Dermatographism As therapy for anaphylactic reactions adjunctive to epinephrine and other standard measures after the acute manifestations have been controlled.
The treatment for cold urticaria is cyproheptadine (PO), as it is indicated for the amelioration of this condition 2.
- Key points:
- Cyproheptadine (PO) is used to treat cold urticaria.
- It can be used as an adjunct to other treatments, such as epinephrine, for anaphylactic reactions.
From the Research
Treatment Options for Cold Urticaria
- Antihistamines are the primary treatment for cold urticaria, with second-generation H1 antihistamines being the first line of treatment 3
- Cyproheptadine has been shown to be effective in treating cold urticaria, with its principal effect being that of an H1 receptor antagonist, blocking the effects of histamine 4
- In cases where patients are unresponsive to initial treatment with H1 antihistamines, further management options may be necessary, including avoidance of cold exposure 3
- For mild to moderate cases, the primary goal of therapy is to improve the patient's quality of life, while in more severe cases, treatment measures to protect the patient's airway, breathing, and circulation may be necessary 3
Additional Considerations
- A sufficient dose of any standard antihistamine should be similarly effective in treating cold urticaria, and patients who do not tolerate one antihistamine or do not appear to respond to it should be tried on other antihistamines of the H1 type 4
- While there are few studies on the use of antihistamines in the treatment of cold urticaria, loratadine or cetirizine may be effective treatments for chronic idiopathic urticaria, which may also be applicable to cold urticaria 5
- Glucocorticosteroids may be used for short periods in cases where antihistamines fail to control symptoms, but their use should be limited to reach an effective low, alternate-day dose followed by discontinuation 6, 7