Cold Urticaria: Why Some People Break Out Into Hives From Cold Exposure And How To Treat It, Per Doctors

Originally published in Women’s Health Magazine

During the winter, you may struggle to feel warm no matter how much you bundle up. But some people actually break out in hives when exposed to cold, whether they’re outdoors in the winter, walking through the freezer aisle at the grocery store, holding an icy beverage, or even sitting in an air-conditioned room.

This reaction is due to a rare condition affecting about 0.05 percent of people known as cold urticaria, which is a “physical form of chronic urticaria, or hives,” explains Walter Ryan, DO, an allergist and immunologist at Dartmouth Health in Nashua, New Hampshire. “It’s not a true cold allergy, but rather a skin condition where the immune system overreacts to cold exposure, releasing histamine and other chemicals.” (Cold sensitivity is different from person to person, so the exact temperature that can trigger symptoms varies.)

Hives, or red, itchy welts, can appear within minutes of exposure to cold (or as your skin warms back up) and may last 30 minutes to a couple of hours, Dr. Ryan adds. You may also experience swelling in the tongue, throat, eyelids, and lips. In extreme cases, cold urticaria can lead to anaphylaxis, says Sharlene Llanes, MD, an allergist and immunologist at Allervie Health in Loxahatchee, Florida.

Here’s what to know about the condition, how to manage it, and when to seek medical attention.

Why Cold Urticaria Happens

Doctors don’t fully understand why some people develop cold urticaria, says Manav Singla, MD, an allergist and immunologist at MedStar Health in Baltimore, Maryland. However, it can appear out of nowhere and start at any age, says Dr. Ryan.

It’s also more common in these groups of people, according to Dr. Singla and Dr. Ryan:

• Those living in colder climates
• Those with allergies in general
• Those who are prone to hives caused by other triggers, such as foods, medications, pet dander, or detergents
• Adults in their 20s to 40s
• Women

Cold urticaria is also sometimes related to underlying medical conditions, such as autoimmune disorders like cryoglobulinemia (where abnormal blood proteins thicken in the cold), viral infections, or blood disorders, Dr. Ryan says.

How Cold Urticaria Is Diagnosed

An old school tool for diagnosing cold urticaria is the “ice cube test,” says Purvi Parikh, MD, a New York City allergist and immunologist with Allergy & Asthma Network. Allergists will put ice cubes on someone’s skin to see if there’s a reaction (hives) in a controlled environment. “Initially, the skin usually just becomes red, but as the area warms back up after the ice is removed, a typical welt or hive develops with swelling, irritation, and itch,” Dr. Singla says. “That reaction supports the diagnosis of cold urticaria.”

However, doctors also commonly diagnose the condition based on someone’s history and reported symptoms. “Most patients come in with a very clear story linking their hives to cold exposure,” Dr. Singla says.

Doctors may also do blood tests to rule out other medical conditions, such as autoimmune diseases, Dr. Llanes adds.

When To Worry About Cold Urticaria

Most cases aren’t dangerous. But Dr. Ryan says to seek urgent medical attention if you have these symptoms:

• Dizziness
• Shortness of breath
• Fainting
• Swelling of the tongue or throat
• Vomiting
• Nausea
• Coughing or wheezing
• Rapid or slow heart rate
• Abdominal pain or cramping
• Diarrhea
• Swelling or pain in the joints
• Red, swollen eyes
• Fever

Once the typical cold-induced hives go away, if other symptoms—like pain or fatigue—linger, see your doctor. You may need to be evaluated for another medical condition, such as an autoimmune condition or blood disorder, Dr. Singla says.

How To Manage Cold Urticaria

Unfortunately, there’s no cure for the condition, which may stop after a few years, or last a lifetime, per the Cleveland Clinic. However, Dr. Llanes says it can be controlled. One way, of course, is to try to avoid cold exposure, like not drinking icy drinks or spending time in cold water, through swimming or a cold plunge. “The most dangerous trigger is cold water immersion because it can cause widespread hives, fainting, or even shock,” Dr. Ryan says.

However, it’s not always possible to avoid triggers. So, “if you know you’re going to be out in cold weather, it’s important to bundle up and cover exposed skin,” adds Dr. Singla.

Those who really can’t avoid triggers may need to take medications, Dr. Parikh says. This may include taking non-drowsy oral antihistamines, such as cetirizine (Zytec), loratadine (Claritin), fexofenadine (Allegra), or levocetirizine (Xyzal), Dr. Singla says. For chronic or severe cases of cold urticaria—like, when fainting or shock are involved—the biologic injectable medication omalizumab (Xolair) or an epinephrine autoinjector (often known by the brand EpiPen) may be prescribed, Dr. Ryan says.

It’s obviously less than ideal to deal with cold urticaria, but at least there are surefire ways to manage it. So, it may be time to say goodbye to cold plunges—and hello to the sauna and steam room.