D3.31 - Successful Management of Primary Cold Urticaria in Medical Practitioners: A Small Case Series

Cold urticaria (ColdU) is a form of inducible chronic urticaria triggered by low temperatures, diagnosed through cold stimulation tests, such as the TempTest. ColdU can be primary or associated with infectious, autoimmune, and lymphoproliferative diseases. Although ColdU affects only 0.05% of the general population, it significantly impacts quality of life and remains challenging to treat. Primary management includes trigger avoidance and regular use of antihistamines (often ineffective), while off-label administration of omalizumab is the recommended second line of treatment.

We report three cases of primary ColdU in medical practitioners with negative extended work-up for other etiologies and positive TempTests, all of whom fully responded to high doses of antihistamines.

Patient 1 is an atopic 41-year-old male abdominal surgeon reporting localized urticaria wheals after cold object contact and generalized urticaria after seawater immersion. TempTest was positive between 4 and 24°C. Full response was achieved with two tablets of 10 mg rupatadine daily.

Patient 2 is an atopic 35-year-old female nephrologist, describing extensive urticarial lesions  starting soon after low-temperature exposure during a mountain hike. TempTest was positive between 4 and 18°C. Initial treatment with four 5 mg levocetirizine tablets daily caused adverse events (drowsiness, tiredness). Switching to 5 mg desloratadine reduced symptoms but retained tiredness, leading to a step-down to two tablets daily, ensuring symptom control alongside trigger avoidance.

Patient 3 is a 26-year-old female rheumatologist with autoimmune thyroiditis, Raynaud’s disease, and Gilbert’s syndrome, experiencing localized urticaria after cold exposure and mucosal edema after ingesting ice cream. TempTest was positive between 4 and 14°C. Daily 5 mg desloratadine was prescribed, achieving symptom remission, and treatment was later adjusted to as-needed antihistamines.

ColdU can be particularly disabling in healthcare workers due to its impact on occupational tasks. Even though all patients presented severe sensitivity through TempTests (below 10°C), low-dose antihistamines provided effective symptom control. The variability in antihistamine efficacy observed in these cases highlights the urgent need for standardized treatment guidelines. Establishing a link between TempTest thresholds and antihistamine response could guide dosing in clinical practice. Further research on larger cohorts might uncover trends, helping refine personalized antihistamine dosing strategies.