Cold urticaria

Background

• Subtype of physical urticaria (i.e. urticaria in response to a physical stimulus)
• In rare cases, can lead to fatal anaphylaxis
• Epidemiology
  • M=F
  • Most common in young adults (20-30 y/o)
  • 50% of patients improve within 5 years
• Cold stimulus can include:
  • Handling cold items/objects
  • Cold environments
  • Swimming in or other exposure to cold water
  • Ingestion of cold food/liquid

Clinical Features

• Localized or diffuse urticaria in response to cold stimulus
• Severe cases can present with angioedema or anaphylaxis

Differential Diagnosis

Acute allergic reaction

• Allergic reaction/urticaria
• Anaphylaxis
• Angioedema
• Anxiety attack
• Asthma exacerbation
• Carcinoid syndrome
• Cold urticaria
• Contrast induced allergic reaction
• Scombroid
• Shock
• Transfusion reaction

Cold injuries

• Generalized
  • Accidental hypothermia
  • Therapeutic hypothermia
• Freezing
  • Frostbite
• Non-freezing
  • Trench foot
  • Chilblains (Pernio)
  • Cold panniculitis
  • Cold urticaria
  • Polar thigh

Evaluation

• Cold Stimulation Test (CST) is main diagnostic test
  • Ice cube (or other object at 0-4° C) placed on forearm for 5 minutes
  • Test is positive if weal develops after 5-10 minutes of rewarming
• Consider lab testing:
  • CBC if suspect infection
  • C1 esterase inhibitor level in cases of angioedema
  • ESR/CRP if suspect underlying autoimmune disease

Management

• Antihistamines (preferably second generation)
• Avoid cold exposure (wear protective clothing if unavoidable)

Disposition

• Generally may be discharged
• Admit if severe angioedema or respiratory involvement

See Also

• Cold injuries