From the Guidelines
Cold-induced urticaria is a type of physical urticaria that is triggered by cold temperatures, causing hives, redness, itching, and swelling, and is classified as a thermal urticaria, specifically cold contact urticaria, as defined in the guidelines for evaluation and management of urticaria in adults and children 1.
Definition and Classification
Cold-induced urticaria is a skin reaction that occurs when the skin is exposed to cold temperatures, causing an immune system reaction that releases histamine and other inflammatory chemicals when the skin warms back up after being cold. This condition is part of the physical urticarias, which are triggered reproducibly by one or more physical stimuli, including mechanical or thermal stimuli, as outlined in the British Journal of Dermatology guidelines 1.
Symptoms and Treatment
Symptoms of cold-induced urticaria typically appear within minutes of cold exposure and can last for about 1-2 hours. Treatment primarily involves avoiding cold triggers and taking antihistamines like cetirizine (10mg daily), fexofenadine (180mg daily), or loratadine (10mg daily) before anticipated cold exposure, as suggested by the guidelines for evaluation and management of urticaria in adults and children 1. For severe cases, higher doses of antihistamines or adding medications like montelukast (10mg daily) may be necessary. People with this condition should carry an epinephrine auto-injector (EpiPen) if they've had severe reactions, as full-body exposure to cold (like swimming in cold water) can potentially cause anaphylaxis with symptoms including difficulty breathing, dizziness, and loss of consciousness.
Management and Prevention
The condition may resolve on its own over time, but many people need ongoing management to prevent uncomfortable and potentially dangerous reactions. Immunomodulating therapies, such as ciclosporin, have been effective in treating chronic urticaria, including cold-induced urticaria, as reported in the guidelines for evaluation and management of urticaria in adults and children 1. However, the optimal patient selection, dose, and duration of treatment still need to be defined. Some key points to consider in the management of cold-induced urticaria include:
- Avoiding cold triggers
- Taking antihistamines before anticipated cold exposure
- Carrying an epinephrine auto-injector (EpiPen) for severe reactions
- Considering immunomodulating therapies for severe cases
- Monitoring for signs of anaphylaxis, such as difficulty breathing, dizziness, and loss of consciousness.
From the Research
Definition and Characteristics of Cold-Induced Urticaria
- Cold-induced urticaria is a subtype of physical urticaria and the second most common type of chronic inducible urticaria 2.
- It is characterized by the development of wheals, angioedema, or both in response to cold exposure 3.
- Symptoms can range from benign and self-limiting to severe systemic anaphylactic reactions 4.
Diagnosis and Testing
- Diagnosis relies on the patient's history and cold stimulation testing, such as the ice cube test 2, 3.
- Clinical testing helps define disease subtypes, including acquired, atypical, and hereditary forms 4.
- Additional diagnostic work-up, including a search for underlying infections, should only be done if indicated by the patient's history 3.
Management and Treatment
- Management includes cold avoidance, the regular use of nonsedating antihistamines, and the off-label use of omalizumab 3.
- Desensitization to cold can be beneficial for patients who do not respond to antihistamines 5.
- Second-generation H1 antihistamines are the first line of treatment, but patients who are unresponsive may require further management options 6.
- In severe cases, treatment measures to protect the patient's airway, breathing, and circulation may be necessary 6.