D3.278 - Cold urticaria: a case report

Cold-induced urticaria is a subtype of physical or inducible urticaria, characterised by thedevelopment of wheals or angioedema provoked by cold exposure. Triggers include diverse cold stimuli, such as aquatic activities and the consumption of cold foods or beverages. Epidemiological data suggest an incidence of 0.05% in Central Europe, with higher prevalence reported in patients with atopy. Pediatric studies report anaphylaxis in approximately 37% of affected children, emphasizing the necessity of increased clinical vigilance and early diagnosis to mitigate the risk of severe complications.

We report the case of a 13-year-old patient with a three-year history of recurrent urticarial lesionslocalized to skin areas exposed to cold surfaces. Notably, the patient reported episodes of vomiting, dizziness, and blurred vision while swimming in a lake, suggestive of systemic involvement. These symptoms resolved spontaneously within one hour without treatment. No loss of consciousness, respiratory distress, or exercise-/food-related triggers were identified. No family history for cold urticaria or atopy.

A cold stimulation test confirmed the diagnosis: an ice cube encased in a plastic bag was applied tothe patient’s forearm for five minutes, followed by reassessment after 10 minutes. An itchy wheal with surrounding erythema and raised, well-defined edges developed at the test site. Laboratory evaluations—including complete blood count, thyroid/liver/renal function panels, serum tryptase, and c-kit (CD117) levels—yielded results within normal reference ranges. The patient was prescribed antihistamine prophylaxis, prioritized given his residence in a high altitude region with prolonged cold exposure. An auto-injectable epinephrine was also prescribed for potential systemic reactions. Additionally, the patient was advised to avoid diving, direct cold exposure without adequate protection, and ingestion of cold foods and beverages.

Cold-induced urticaria is an underdiagnosed condition with substantial implications for patientsafety due to the risk of systemic reactions, such as anaphylaxis. While rare, cold-inducedanaphylaxis constitutes a life-threatening complication that warrants further investigation to better understand its pathophysiology and improve management strategies. The creation of aninternational case registry could provide valuable data to guide research and clinical practice.Cold avoidance remains the primary preventive measure, although not always feasible. Antihistamines are the primary prophylactic treatment, with other biological therapies such as Omalizumab—a monoclonal anti-IgE antibody—showing promise. Emerging biologic drugs may offer therapeutic potential for patients with this complex condition. Raising awareness among clinicians and patients is essential to ensure timely diagnosis, effective treatment, and improved outcomes for individuals affected by cold-induced urticaria.