Yes, You Really Can Be "Allergic" to the Cold

Yes, You Really Can Be Posted By:

Cold-induced urticaria is a subtype of chronic inducible urticaria that affects approximately 0.05% of the global population. Unlike chronic spontaneous urticaria, which has no identifiable trigger, cold urticaria is triggered by exposure to cold weather, air, or water. It can result in hives and/or angioedema, and is known to trigger severe, possibly life-threatening anaphylaxis; it is associated with significant morbidity due to the constant vigilance required to avoid cold weather or water. Diagnosis of cold urticaria is often made based on clinical history and positive ice cube test in the office. Treatment involves avoidance of cold triggers and the use of non-sedating, second-generation H1-antihistamines, often up to 4-times the normal dose. Patients should be prescribed an epinephrine autoinjector to manage any potentially severe anaphylactic reactions.

Prosty et al recently completed a systematic review and meta-analysis on cold urticaria. The selected articles included a total of 1135 patients with cold urticaria. The median age of onset of cold urticaria in studies with pediatric patients was between 8 and 8.5 years old; in studies with pediatric and adult patients, it was between 22 and 27 years old. Approximately 94% of studies used the ice cube test as a diagnostic method. Among patients with chronic urticaria in general, the prevalence of cold urticaria (both as its own disease state or co-existing with another type of chronic urticaria) was found to be approximately 8% to 26%, and appeared more likely to occur comorbidly with another type of chronic urticaria than as its own disease. The study reports that the most common trigger of cold urticaria was exposure to cold water (63% to 92%), followed by cold air or weather (58% to 82%). Exposure to cold surfaces/objects or ingestion of cold food/beverages triggered hives in as many as 73% and 20% of patients, respectively, and more than 44% of patients were triggered by localized exposure to cold fluid (eg, during hand washing).

Regarding treatment options, Prosty et al found that non-sedating, second-generation H1-antihistamines were most used to manage cold urticaria (95.67% of patients), using up to 4-fold the normal dose. Other treatments utilized for cold urticaria with varying degrees of success were omalizumab, cyclosporine, H2-antihistamines, oral corticosteroids, antileukotrienes, and doxepin. In studies evaluating symptom control in response to treatment, most patients (67%) responded to H1-antihistamines alone. Of the patients in that same study analysis managed with omalizumab or oral corticosteroids, none had control of symptoms. However, other studies included in the analysis found omalizumab to be effective for symptom control in up to 100% of patients, which demonstrates there may be a place for omalizumab as adjunctive therapy in cold urticaria or as an option for patients refractory to H1-antihistamines.

Among the meta-analyses, approximately 14% of adult patients had resolution of cold urticaria at 5 years, and 43% had resolution of the condition at 10 years. When evaluating for cases of anaphylaxis due to cold urticaria, the number of patients (both adult and pediatric) experiencing anaphylaxis ranged broadly from 0% to 34%. Fortunately, there were no reported fatalities secondary to cold-induced symptoms. Of patients who had a history of anaphylaxis to cold, swimming was the most common trigger—though temperature of the water was not reported.

Though rare, cold-induced urticaria is severe. Thus, it is important for providers to be aware of its presentation, recommended management options, and the overall lack of response to oral corticosteroids. Patients with cold urticaria and their caregivers should be educated on avoiding cold triggers and full-body immersion in cold water. They should also be educated on recognition of anaphylaxis and proper use of epinephrine autoinjectors. Prompt referral to an allergist to discuss symptoms and possible off-label use of omalizumab may be necessary in refractory cases.

  • Ngan V. Cold urticaria. Accessed March 11, 2022.
  • Prosty C, et al. Prevalence, management, and anaphylaxis risk of cold urticaria: A systematic review and meta-analysis. J Allergy Clin Immunol Pract. 2022;10:586.


Filed under: Curbside Consultations , Allergy/Immunology

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