Get hives and wheezing when it’s cold? It may be cold urticaria

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November 14, 2022 — Yvette Braunstein, a social worker at a New York City hospital, develops hives when exposed to the cold, whether it be cold weather outdoors or cold objects such as ice water. Braunstein has a condition called “cold urticaria.”

Cold urticaria is a type of rash in a category called chronic inducible urticaria or physical urticaria, says Edwin Kim, MD, assistant professor of medicine at the University of North Carolina and director of the UNC Allergy and Immunology Clinic.

“In cold urticaria, patients develop red, raised, itchy bumps — hives — after exposure to cold,” he says. This can happen when the person encounters cold water or cold air, e.g. B. when she is outdoors in winter or standing in front of an air conditioner.

“The bumps usually look like mosquito bites but can occasionally blend into much larger rashes. The most obvious symptoms will be significant itching,” Kim said.

In addition to hives, Braunstein has difficulty breathing in cold weather. She develops shortness of breath, chest tightness, coughing, wheezing, and even occasionally dizziness. “I also can’t eat or drink very cold or frozen foods like ice water or ice cream, nor can I touch cold things like an ice cube,” she says.

Types of cold urticaria

There are two types of cold urticaria: In acquired (also essential) urticaria, the symptoms appear about 2 to 5 minutes after contact with the cold trigger. They usually last 1 to 2 hours before dissipating.

In hereditary (or familial) cold urticaria, symptoms take longer to appear—usually between 24 and 28 hours after exposure to a trigger. They also last longer, typically around 24 hours, but they can last up to 48 hours.

Kim explains that what appears to be an environmental or external trigger is causing allergic immune cells in the patient’s skin (called mast cells) to release histamine. Histamines are chemicals made by the immune system that help the body get rid of irritants (allergens), thereby causing allergy symptoms such as hives, wheezing, or itching. “In the case of cold urticaria, it’s the cold that does it, although we still don’t know how or why it happens.”

Braunstein acquired urticaria. “I first noticed it the summer before my senior year of high school when I was 17,” she says. “I would get huge welts if I was near an air conditioner in a house or car. I was a counselor at day camp and every time I got out of the pool I was covered in hives.”

Braunstein didn’t connect these events until late summer, when her parents took her to an allergist and she mentioned both triggers to him. “He did an ‘ice cube test,’ which literally meant putting an ice cube on my arm or leg for a period of time to see if there was a reaction, and I had a reaction right where the ice was .”

There is no blood test to detect cold urticaria. Sarbjit Saini, MD, program director and professor of medicine at Johns Hopkins University School of Medicine in Baltimore, says that diagnosing cold urticaria involves a thorough medical history, physical examination, and performing a cold challenge test, such as the ice cube test, to check for skin reactions in the area of ​​contact.

Self-Care Measures

The first way to combat cold urticaria is to try to avoid the cold as much as possible. “Cover up in cold weather,” says Saini. “Wear gloves, hats, scarves and avoid swimming in cold water. Also, avoid drinking cold liquids.”

Kim agrees, adding that these will help but are “not perfect and unfortunately not always feasible in many cases.”

Braunstein dresses in warm clothes in winter, including a warm coat with a fur hood, and special thermal underwear, and tries to keep her neck covered. She also tries to avoid being outside as much as possible. And she can no longer go swimming even in warm weather. “I try not to get wet because being wet cools the body down,” she says. Speaking while breathing cold air makes symptoms worse, so Braunstein avoids this as much as possible.

Some research suggests that acupuncture may be helpful in other types of urticaria and may also have benefits in cold urticaria.

Medicines for cold urticaria

According to Kim and Saini, antihistamines are the mainstay of drug treatment for cold urticaria. These include cetirizine (Zyrtec), fexofenadine (Allegra), loratadine (Claritin), and levocetirizine (Xyzal).

Braunstein takes fexofenadine in the morning and afternoon and cetirizine in the evening. She is also being treated with montelukast (Singulair), a drug often used for asthma.

Another drug sometimes used to treat cold urticaria is omalizumab (Xolair), which is commonly prescribed for wheezing or shortness of breath in people with asthma.

When to get help

In people with cold urticaria, exposure to cold can occasionally (though rarely) lead to anaphylaxis, a serious life-threatening condition that may include coughing, wheezing, pain, itching, or chest tightness; Fainting, dizziness, confusion or weakness, fast heartbeat, swollen or itchy throat or tongue, paleness and a weak pulse. Saini and Kim urge people who are experiencing symptoms of anaphylaxis to go to the emergency room for immediate medical care.

Anaphylaxis is treated with an epinephrine auto-injector (EpiPen) that patients carry with them. Braunstein has an EpiPen but luckily didn’t have to use it.

Cold urticaria is a difficult condition to live with, but avoiding the cold as much as possible and taking medication as prescribed can make it significantly better to manage.



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