Treatment of Cold Urticaria
Start with second-generation H1 antihistamines (cetirizine, fexofenadine, loratadine, desloratadine, or levocetirizine) as first-line therapy, and if inadequate control occurs after 2-4 weeks, increase the dose up to 4-fold before considering alternative agents. 1
First-Line Treatment Algorithm
Begin with second-generation H1 antihistamines as the foundation of therapy for cold urticaria, as recommended by the British Journal of Dermatology for all physical urticarias. 1
Trial at least two different non-sedating antihistamines because individual patient responses vary significantly—what fails in one patient may work excellently in another. 1
Consider cetirizine first when rapid symptom control is needed for cold exposure, as it reaches maximum concentration fastest among the second-generation agents. 1
Updose to 4-fold the standard dose if inadequate control occurs after 2-4 weeks on standard dosing before switching to alternative agents. 1 Over 40% of patients show good response to antihistamines at appropriate doses. 2
Second-Line and Combination Therapies
Add H2 antihistamines (cimetidine) to H1 blockers if symptoms persist, as this combination may provide better urticaria control than H1 antihistamines alone. 1
Consider cyproheptadine as a sedating alternative if second-generation agents fail, as it functions as both an H1 antihistamine and antiserotonergic agent, which may explain superior efficacy specifically in cold urticaria. 1 Historical data supports combination therapy with hydroxyzine plus cimetidine reaching statistical significance (P = 0.01) for suppression of erythema in cold urticaria. 3
Third-Line Therapy for Refractory Cases
Escalate to omalizumab 300 mg every 4 weeks if symptoms remain uncontrolled despite 4-fold dosing of second-generation antihistamines and trial of cyproheptadine. 1 This represents the evidence-based approach for antihistamine-resistant chronic urticaria. 2
Consider cyclosporine for severe autoimmune urticaria unresponsive to omalizumab, though this is rarely needed for cold urticaria specifically. 2
Critical Management Principles
Use antihistamines on a regular prophylactic basis, not only after hives occur, as cold urticaria is a chronic stimulus-dependent condition requiring ongoing treatment as long as cold exposure remains part of the patient's environment. 1, 4
Avoid first-generation antihistamines as monotherapy when second-generation agents haven't been tried at standard and increased doses first. 1
Do not combine sedating antihistamines at bedtime with second-generation agents during the day, as this causes prolonged daytime drowsiness without meaningful additional H1 blockade. 1
Exercise extreme caution with cyproheptadine and diphenhydramine in elderly patients due to anticholinergic risks including cognitive decline. 1
Important Caveats and Pitfalls
Avoid NSAIDs and aspirin, as they can worsen urticaria through cyclooxygenase inhibition. 1
Minimize aggravating factors including overheating, stress, and alcohol. 1
Do not use topical steroids routinely for urticaria, as the British Journal of Dermatology guidelines explicitly state this is not recommended despite some limited reports of benefit in specific contexts. 2 The migratory nature of wheals (lasting 2-24 hours and appearing in different locations) makes topical therapy impractical. 2
Recognize that cold urticaria persists indefinitely and requires continuous prophylactic therapy rather than time-limited treatment—the 50% clearance at 6 months data applies to ordinary chronic urticaria, not physical urticarias like cold urticaria. 1
Avoid short-term corticosteroids as they only suppress symptoms partially and temporarily in cold urticaria, and long-term use leads to significant morbidity without addressing underlying disease. 5, 6
Non-Pharmacological Management
Avoidance of cold exposure is the most effective prophylactic measure and should be emphasized alongside pharmacological therapy. 7
In severe cases with angioedema or anaphylaxis risk, ensure patients have epinephrine autoinjectors and proper training, particularly if considering omalizumab therapy which carries a 0.2% anaphylaxis risk. 5