What is the treatment for cold-induced urticaria (hives) in a patient allergic to cold temperatures?

From the Guidelines

The treatment for cold-induced urticaria primarily involves antihistamines, with second-generation H1 antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) being the first-line therapy, as recommended by the latest guidelines 1.

Key Considerations

• These medications should be taken regularly rather than as needed to maintain consistent protection.
• For severe cases, dosing may be increased up to four times the standard dose under medical supervision, following the "as much as needed and as little as possible" approach 1.
• Additional treatments include adding H2 antihistamines like ranitidine (150mg twice daily) or famotidine (20mg twice daily), or leukotriene receptor antagonists such as montelukast (10mg daily for adults).
• For breakthrough reactions, patients should carry an epinephrine auto-injector (like EpiPen) for emergency use.

Practical Management

• Practical management also involves avoiding cold exposure, wearing warm clothing, and gradually acclimating to cold environments.
• Cold desensitization therapy may help some patients by gradually exposing them to increasingly colder temperatures under medical supervision, as supported by general measures and information that can be helpful for most patients with urticaria 1.
• This approach works because antihistamines block histamine receptors, preventing mast cell degranulation that occurs when cold temperatures trigger autoantibodies to bind to skin mast cells, releasing inflammatory mediators that cause hives, swelling, and potentially systemic reactions.

Treatment Algorithm

• The recommended treatment algorithm features 3 steps: first-line treatment with antihistamines, second-line treatment with omalizumab, and third-line treatment with cyclosporine, with guidance on updosing and duration 1.
• For omalizumab, the recommendation is to start treatment with 300 mg every 4 weeks, and in patients with insufficient response, updosing should be considered, with a maximum recommended dose of 600 mg every 14 days.

From the FDA Drug Label

Cold urticaria Mild, uncomplicated allergic skin manifestations of urticaria and angioedema. As therapy for anaphylactic reactions adjunctive to epinephrine and other standard measures after the acute manifestations have been controlled. The treatment for cold-induced urticaria (hives) in a patient allergic to cold temperatures is cyproheptadine (PO), which can be used to treat cold urticaria and mild, uncomplicated allergic skin manifestations of urticaria and angioedema 2.

From the Research

Treatment Options for Cold-Induced Urticaria

• Second-generation H1 antihistamines are the first line of treatment for cold urticaria, as they have been shown to be effective in improving the patient's quality of life 3, 4.
• In cases where patients are unresponsive to initial treatment with H1 antihistamines, further management options may be necessary, such as the use of epinephrine and supportive care 5.
• Avoidance of cold exposure is the most effective prophylactic measure for preventing cold urticaria symptoms 3, 4.
• In severe cases, treatment measures to protect the patient's airway, breathing, and circulation may be necessary, and patients may require admission to the intensive care unit for monitoring 5.

Additional Treatment Considerations

• Cyproheptadine, an H1 receptor antagonist, has been shown to be effective in ameliorating the symptoms and signs of cold urticaria, and its principal effect is blocking the effects of histamine 6.
• Other antihistamines, such as hydroxyzine, have also been shown to be effective in suppressing erythema and wealing in patients with cold urticaria 7.
• Omalizumab, an off-label treatment, may also be used in the management of cold urticaria, particularly in cases where patients are refractory to initial therapy with H1 antihistamines 4.

Diagnosis and Management

• The diagnosis of cold urticaria relies on the patient's history and cold stimulation testing, and additional diagnostic work-up should only be done if indicated by the patient's history 4.
• The classification of cold urticaria includes typical and atypical subtypes, and the pathophysiology is thought to involve the cold-induced formation of autoallergens and IgE to these autoallergens, which provoke a release of proinflammatory mediators from skin mast cells 4.