Abstract 

Cold-induced urticaria is a chronic physical urticaria marked by itchy wheal and flare responses due to the release of histamine and other proinflammatory mediators after exposure to cold. It may be induced by a wide range of cold triggers such as ingestion of cold substances, cold environments, handling cold objects and aquatic activities. Symptoms may vary from mild localized urticaria, angioedema to anaphylaxis. This exemplifies the importance of accurate diagnosis and management of patients with cold-induced urticaria. The treatment of choice is nonsedating antihistamines, doses of which may be increased up to 4-fold if standard doses are ineffective.

Case Presentation 

A 7-year-old boy accompanied by his parents presented with complaints of redness and itching over his arms, legs and face from the past 1 month.

History 

He had no recent illnesses, however, he mentioned that redness and pruritus often appeared on his arms and face after walking through the freezer aisle of a grocery store. Urticaria subsequently developed on regions where he scratched and spontaneously resolved after 2 to 3 hours. Once urticaria appeared diffusely while he showered after swimming and resolved within a few hours. Two to three days prior to presentation, he experienced upper lip angioedema with erythema, globus sensation and difficulty swallowing after drinking a strawberry slush. He denied having respiratory complaints at that time, and the symptoms again resolved spontaneously. A day later, he tolerated ice cream with no complaints. His family history was not significant. 

Examination

On physical examination, the patient was well-oriented in time, place and person. He had 3 to 4 discrete urticarial lesions on the distal posterior aspect of each calf at that time. The findings of other examinations were unremarkable and dermatographism was absent.

Investigations

• Strawberry radioallergosorbent test and cryoglobulins test findings were negative.
• An ice cube wrapped in plastic was applied to the volar surface of his right forearm for 5 minutes. A 9 × 6 cm wheal was seen 3 minutes after removing the ice. 

Provisional Diagnosis

A diagnosis of cold urticaria associated with angioedema was established. 

Discussion

Cold-induced urticaria is a subtype of physical urticaria. Statistics indicate that 6-34% of individuals with physical urticaria have cold-induced urticaria. Higher frequency is more common in regions with colder environments. It may affect individuals of any age, the age being quite broad varying from 3 months to 74 years. Although the precise pathogenesis remains obscure, it is has been suggested that IgE antibodies react against specific skin antigens at the appropriate temperature, which causes release of histamine and other inflammatory mediators.

With cold stimuli being very common, under-diagnosis or misdiagnosis of this condition could worsen the quality of life of affected individuals. Therefore, timely diagnosis and appropriate management is of paramount importance. Patients must be reassured about the usually benign course of the disease and advised to protect the body surfaces when cold exposure is inevitable as well as to avoid rapid exposure to cold water. Furthermore, second-generation antihistamines are the agents commonly used to treat cold-induced urticaria. 

Suggested Reading

Hochstadter EF, Ben-Shoshan M. Cold-induced urticaria: challenges in diagnosis and management. BMJ Case Rep. 2013;2013:bcr2013010441.