Cold Urticaria in the New York Times

From the NYTimes:

“I think I’m going to faint,” the tall, 35-year-old man said, grabbing the handrail of the stairs that led up from the beach. His brother turned back to see his older sibling collapse onto the sandy wooden planking.

In the ER, the patient said he was fine until he went swimming that day. But after being in the water for a while, he began to feel lightheaded, and the skin on his hands and feet felt tight, as if it had shrunk in the wash.

The patient’s wife was really worried. An allergy induced by the cold? She sat down at the computer and looked up “allergy induced by the cold.” Up came something she had never heard of: cold-induced urticaria — an allergy to cold itself.

Paradoxically, it is the warmer months that carry the greatest threat; that’s when the sparkling waters of the ocean or neighborhood pool beckon or an unseasonably cool evening can catch you unaware and unprepared. It’s not unusual that his worst symptoms came while swimming, when his entire body was exposed to the cold, the doctor said."

Diagram (mind map) of acute urticaria (click to enlarge the images).

Diagram (mind map) of chronic urticaria (click to enlarge the images).

Physical urticarias

Physical urticaria is defined as hives provoked by physical stimulus such as:


Cold urticaria due to cooling the skin
Dermographism due to stroking the skin
Cholinergic urticaria due to exercise, emotion, or heat
Solar urticaria due to sun exposure

Physical urticaria can be confirmed by challenge testing, and is best treated symptomatically by avoidance of provocative stimuli and antihistamines.

Physical urticaria does not respond to steroids since they do not inhibit mast cell degranulation.

Testing procedures for diagnosis of physical urticarias depend on the cause (stimulus):

- Dermographism: Stroking with narrow object, e.g. a tongue depressor
- Cold urticaria: ice cube test
- Heat urticaria: test tube water at 44°C (111°F)
- Pressure urticaria: Sandbag test or a bag with heavy books (Middleton's Allergy textbook, 2 volumes)
- Vibratory urticaria: vibration with laboratory vortex for four minutes
- Cholinergic urticaria: exercise for 15-20 minutes or leg immersion in 44°C (111°F) bath
- Aquagenic urticaria: challenge with tap water at various temperatures

Related reading:
"Young mother must wrap up all year round because she is allergic to the cold" - Cold urticaria in Daily Mail.


  1. Anonymous4/06/2010

    From Google Buzz:

    Jeffrey Benabio, MD - I have seen this more frequently in people who exercise -- runners who run in the morning when temps can be in the 40's and 50's. (Not now of course, this is San Diego after all). ;) 1:50 pm

    Vamsi Balakrishnan - Dermatographia urticaria I think is the most...interesting allergy-related condition that I've learned in med school so far. 3:15 pm

    Ves Dimov, M.D. - Dermatographism is actually not "true" allergy. The release of histamine is triggered by a physical stimulus (pressure) rather than specific antigen binding. 3:19 pm

    Vamsi Balakrishnan - Ah, didn't really think of it that way. I just remember learning it's the most common urticaria...and the pictures I've seen are...interesting always.

    So, a true allergy is always defined as "release of histamine from mast cells due to IgE allergen binding" but not any other cause (rupture, etc.)? 3:28 pm

  2. What is even more bizzare is that cold urticaria and cholinergic urticaria can sometimes co-exist within the same person.

    Imagine getting hives when you get hot or cold? That would be a nightmare.

    I have cholinergic urticaria, so I know first-hand how frustrating these urticarias are to deal with.