1. Alix, Susan DNP, RN

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We don't often see patients with cold-induced urticaria. In fact, I had never heard of this condition until it happened to my 12-year-old daughter. It occurred one day when the cold rain fell onto her exposed arms. Small welts appeared that continued to get bigger and connect to one another to form even bigger wheals. When the allergist diagnosed her with cold urticarial, we were stunned: How can someone be allergic to the cold, especially when they live in New England?


A rare allergy

Cold urticaria is a relatively rare, yet very real allergy, accounting for approximately 1% to 3% of all urticaria cases in the United States, according to the National Organization for Rare Disorders. It's considered a subtype of physical urticaria-a rash triggered by a physical stimulus, such as pressure, cold, sweating, sunlight, or water-and may be underestimated due to undetected or unreported cases, although there's a higher prevalence in colder environments.


Cold urticaria occurs when a person is exposed to any cold stimuli of variable duration, such as cold, damp, or windy weather; water activities; eating or drinking cold foods or liquids; and/or handling cold objects. It occurs equally in men and women, although more commonly in young adults age 20 to 30. Rarely, its occurrence is seen in families. Cold urticaria can last anywhere from 4 to 9 years, but individuals usually have some improvement in symptoms within 5 years.


Symptoms are usually noticeable minutes after the skin has been exposed to the stimulus and are characterized by the following:


* temporary reddish, itchy welts or wheals (hives) on the area of skin that was exposed to cold (see Picturing cold urticaria)


* swelling of the hands when holding cold objects


* swelling of the lips and throat (angioedema) when consuming cold food or drink.



These symptoms are caused by the release of histamine, leukotrienes, and other proinflammatory mast cell mediators after the skin is exposed to cold. If the stimulus isn't removed, the condition may progress to a more systemic reaction, including headache, dyspnea, hypotension, and loss of consciousness. Why a cold stimulus causes activation of mast cells and subsequent release of histamine and other inflammatory mediators still remains unknown.


Ice cubes as diagnostic tool

Assess the patient presenting with cold urticaria for symptoms, manifestations, and precipitating factors. Because cold urticaria frequently goes unrecognized, perform a thorough history, including past medical history (preexisting allergies) and recent events (ingestion of new foods or exposure to new environments). Many individuals are unaware that physical stimuli can cause urticaria, so it's crucial to ask specifically about these as possible precipitating factors.


Routine lab tests, including a complete blood cell count, chemistry profile, erythrocyte sedimentation rate, and antinuclear antibody, may be ordered, along with more selective tests, such as serum immunoglobulin (Ig) E and IgM. Serum cryoglobulin and complement assays may be useful because cryoglobulinemia is associated with some forms of cold-induced urticaria.


However, the main diagnostic test is the cold stimulation test, otherwise known as the ice cube challenge. With this test, an ice cube is placed on the ventral (underside) surface of the arm for 4 to 5 minutes. The examiner will then evaluate the site at intervals of 1, 3, 5, and 10 minutes for the appearance of a pruritic wheal or wheals. If a wheal is visualized, the diagnosis of cold urticaria is made.


Avoiding triggers

There's no definitive therapy for the treatment of cold urticaria. Patient education regarding the avoidance of cold stimuli or triggers is the best practice. Possible medications include diphenhydramine, cetirizine, and leukotriene antagonists; however, they may produce ineffective results.


Instruct patients who experience wheals to remove any cold, wet clothing touching the affected skin area and warm their skin temperature. Most patients report that by the time they've ingested diphenhydramine, the wheals have already started to disappear and they're then left with fatigue from the medication.


According to the National Organization for Rare Disorders, individuals may attempt desensitization by repeated exposures to cold, such as regularly taking cold showers.


Yes, it's possible!

Fifteen years later, my daughter still has some reactions to the cold, although less often and not as severe. People still don't understand her condition or really believe that it exists. But all she has to do is take out an ice cube and place it on her arm as proof.


on the web


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Cleveland Clinic


Mayo Clinic


NBC News


New York Times


Today Health


Weather Channel




Claudy A. Cold urticaria. J Investig Dermatol Symp Proc. 2001;6(2):141-142.


Hochstadter EF, Ben-Shoshan M. Cold-induced urticaria: challenges in diagnosis and management. BMJ Case Rep. 2013;2013.


Hogan DJ. Chronic urticaria workup.


National Organization for Rare Disorders. Urticaria, cold.