eMedinewS Editorial

Medicine 3,974 Comments

Cold Urticaria

Cold urticaria is characterized by itchy wheals and/or angioedema due to skin mast cell activation and release of proinflammatory mediators after cold exposure. More than 90% of cold urticaria is idiopathic, the rest are mostly secondary to cryoglobulinemia.1

Cold urticaria is rare in children. Children with cold urticaria have an increased risk of anaphylaxis.2 The symptoms are usually limited to cold–exposed skin areas and develop within minutes of cold exposure. A cold stimulation test (CST) confirms the diagnosis in most and avoidance of cold exposure is the best prophylaxis.

A CST is considered positive when the patient develops urticarial skin lesions at the site of the cold challenge. CSTs are performed using ice cubes, cold packs, cold water baths.

The ice cube test has a sensitivity of 83–90% and a specificity of 100%.3,4 The ice cube should be melting and contained in a thin plastic bag to avoid cold damage of the skin.5 Cold stimulation time thresholds can also be noted.6 This method is readily performed in most clinics. Use of cold packs/cold water baths is not recommended as first–line screening tests, as it may induce systemic reactions.6 But, it may help in confirming the diagnosis in patients who have a negative ice cube test.

Cold stimulation tests are performed for five minutes and test responses are assessed 10 minutes after the end of provocation testing.

  • The test is considered positive if there is a palpable and clearly visible wheal–and–flare skin reaction. This reaction is itchy and/or associated with a burning sensation in most cases.
  • The test is considered negative if there is no reaction, or erythema or pruritus/burning only. Suspected patients who show a negative test should be re–evaluated.

Further testing is performed using larger areas for provocation (e.g. cold pack or cold water bath) or using triggers that induced urticarial reactions earlier (e.g. cold wind, cold water). Atypical cold urticarias should be considered if the additional stimulation tests are also negative.

Treatment involves the use of nonsedating H1 antihistamines for those who are unable to sufficiently avoid cold exposure and have frequent symptoms. Start with second–generation H1 antihistamine at the standard dose and increase upto four times the standard dose as needed. Treat cold–induced anaphylaxis with epinephrine.


  1. Alangari AA, et al. Clinical features and anaphylaxis in children with cold urticaria. Pediatrics 2004;113(4):e313–7.
  2. Anaphylaxis common in children with cold urticaria. Respiratory Reviews 2004;9(6).
  3. Neittaanmoki H. Cold urticaria. Clinical findings in 220 patients. J Am Acad Dermatol 1985;13(4):636–44.
  4. Mathelier–Fusade P, et al. Clinical predictive factors of severity in cold urticaria. Arch Dermatol 1998;134(1):106–7.
  5. Siebenhaar F, et al. Peltier effect-based temperature challenge: an improved method for diagnosing cold urticaria. J Allergy Clin Immunol 2004;114(5):1224–5.
  6. Wanderer AA, et al. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. J Allergy Clin Immunol 1986;78(3 pt 1):417–23.

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor