Cold urticaria

Date Updated: 12/15/2021

Overview

Cold urticaria (ur-tih-KAR-e-uh) is a skin reaction to cold that appears within minutes after cold exposure. Affected skin develops itchy welts (hives).

People with cold urticaria experience widely different symptoms. Some have minor reactions to the cold, while others have severe reactions. For some people with this condition, swimming in cold water could lead to very low blood pressure, fainting or shock.

Cold urticaria occurs most frequently in young adults. If you think you have this condition, consult your doctor. Treatment usually includes preventive steps such as taking antihistamines and avoiding cold air and water.

Symptoms

Cold urticaria signs and symptoms may include:

Temporary itchy welts (hives) on the area of skin that was exposed to cold
A worsening of the reaction as the skin warms
Swelling of hands while holding cold objects
Swelling of lips from consuming cold food or drink

Severe reactions may include:

A whole-body response (anaphylaxis), which can cause fainting, a racing heart, swelling of limbs or torso, and shock
Swelling of the tongue and throat, which can make it difficult to breathe

Cold urticaria symptoms begin soon after the skin is exposed to a sudden drop in air temperature or to cold water. Damp and windy conditions may make a flare of symptoms more likely. Each episode may persist for about two hours.

The worst reactions generally occur with full skin exposure, such as swimming in cold water. Such a reaction could lead to loss of consciousness and drowning.

When to see a doctor

If you have skin reactions after cold exposure, see your doctor. Even if the reactions are mild, your doctor will want to rule out underlying conditions that may be causing the problem.

Seek emergency care if after sudden exposure to cold you experience a whole-body response (anaphylaxis) or difficulty breathing.

Causes

No one knows exactly what causes cold urticaria. Certain people appear to have very sensitive skin cells, due to an inherited trait, a virus or an illness. In the most common forms of this condition, cold triggers the release of histamine and other chemicals into the bloodstream. These chemicals cause hives and sometimes a whole-body (systemic) reaction.

Risk factors

You're more likely to have this condition if:

You're a young adult. The most common type — primary acquired cold urticaria — occurs most frequently in young adults.
You have an underlying health condition. A less common type — secondary acquired cold urticaria — can be caused by an underlying health problem, such as hepatitis or cancer.
You have certain inherited traits. Rarely, cold urticaria is inherited. This familial type causes painful welts and flu-like symptoms after exposure to cold.

Complications

The main possible complication of cold urticaria is a severe reaction that occurs after exposing large areas of skin to cold, for example, by swimming in cold water.

Prevention

The following tips may help prevent a recurrent episode of cold urticaria:

Take an over-the-counter antihistamine before cold exposure.
Take medications as prescribed.
Protect your skin from the cold or sudden changes in temperature. If you're going swimming, dip your hand in the water first and see if you experience a skin reaction.
Avoid ice-cold drinks and food to prevent swelling of your throat.
If your doctor prescribed an epinephrine autoinjector (EpiPen, Auvi-Q, others), keep it with you to help prevent serious reactions.
If you're scheduled for surgery, talk with your surgeon beforehand about your cold urticaria. The surgical team can take steps to help prevent cold-induced symptoms in the operating room.

Diagnosis

Cold urticaria can be diagnosed by placing an ice cube on the skin for five minutes. If you have cold urticaria, a raised bump (hive) will form a few minutes after the ice cube is removed.

In some cases, cold urticaria is caused by an underlying condition that affects the immune system, such as an infection or cancer. If your doctor suspects you have an underlying condition, you may need blood tests or other tests.

Treatment

In some people, cold urticaria goes away on its own after weeks or months. In others, it lasts longer. There is no cure for the condition, but treatment and preventive steps can help.

Your doctor may recommend you try to prevent or reduce symptoms with home remedies, such as using over-the-counter antihistamines and avoiding cold exposure. If that doesn't help, you may need prescription medication.

Prescription medications used to treat cold urticaria include:

Nondrowsy antihistamines. If you know you're going to be exposed to the cold, take an antihistamine beforehand to help prevent a reaction. Examples include loratadine (Claritin) and desloratadine (Clarinex).
Omalizumab (Xolair). Normally prescribed to treat asthma, this drug has been used successfully to treat people with cold urticaria who didn't respond to other medications.

If you have cold urticaria because of an underlying health problem, you may need medications or other treatment for that condition as well. If you have a history of systemic reaction, your doctor may prescribe an epinephrine autoinjector that you'll need to carry with you.

Lifestyle and home remedies

Antihistamines block the symptom-producing release of histamine. They can be used to treat mild symptoms of cold urticaria or to prevent a reaction. Over-the-counter (nonprescription) products include loratadine (Claritin) and cetirizine (Zyrtec Allergy).

Preparing for an appointment

You'll probably first visit your primary care doctor, who may then refer you to a doctor who specializes in skin diseases (dermatologist) or to an allergy specialist (allergist-immunologist).

Preparing a list of questions for your doctor will help you make the most of your time together. For cold urticaria, some basic questions to ask include:

What's the most likely cause of my symptoms?
What are other possible causes for my symptoms?
How long will these hives last?
What kinds of tests do I need? Do these tests require any special preparation?
What treatments are available? Which do you recommend?
Do these treatments have any side effects?
Is there a generic alternative to the medicine you're prescribing?
I have other health problems. Are the recommended treatments compatible?
Do you have any brochures or other printed material I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you questions such as:

When did you begin experiencing symptoms?
Have you recently been ill?
Do others in your family have similar symptoms?
Have you taken any new medications recently?
Have you tried any new foods?
Have you traveled to a new place?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?

What you can do in the meantime

If you're experiencing mild hives, these tips may help relieve your symptoms:

Avoid irritating affected areas.
Avoid whatever you think may have triggered your reaction, such as facing into a cold wind or swimming in cold water.
Minimize vigorous activity, which can release more irritants into your skin.
Use over-the-counter antihistamines to help relieve the itching.