Cold Urticaria: Causes, Symptoms and Treatment Options

This article was originally published in Women’s Health Magazine and features insights from board-certified allergists and immunologists.

If your skin erupts in itchy welts the moment you step out into the cold, walk past the freezer aisle, hold an icy drink, or slip into a cool pool, you’re not imagining it, and you’re not alone. A condition called cold urticaria can bring on hives, swelling, and itching when your skin meets the cold, turning an ordinary winter walk or a dip in the water into something uncomfortable, and occasionally risky.

Our allergists at AllerVie Health can give you expert guidance on how to manage the condition through avoidance and medication. We understand how to make sure you get the help you need that fits your life.

Below, we break down what’s actually happening on your skin, how the condition is diagnosed, the symptoms worth taking seriously, and the everyday steps (and treatments) that help you stay comfortable.

Key Takeaways

• Cold urticaria is a physical form of hives (urticaria)
  It isn’t an allergy to a substance. Instead, cold exposure triggers the same histamine response that drives allergic reactions. That’s why an allergist is the right specialist to diagnose and treat it, and why reactions can range from localized welts to serious whole-body symptoms.
  
• Symptoms usually show up within minutes of cold exposure (or as the skin rewarms)
  Red, itchy welts, and sometimes swelling of the lips, tongue, or throat.
  
• It’s uncommon, affecting roughly 0.05% of people, and can begin at any age, most often in adults in their 20s to 40s.
  
• Most cases aren’t dangerous, but cold-water immersion can trigger a severe, whole-body reaction. Seek urgent care for dizziness, trouble breathing, or fainting.
  
• There’s no cure, but antihistamines, avoidance, and (in severe cases) prescription options make it very manageable. An allergist can build a plan that fits your life.

What Is Cold Urticaria? 

Cold urticaria 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.” So while people often call it a “cold allergy,” it’s really your body’s reaction to a temperature change rather than to a specific substance. It affects about 0.05 percent of people.

Cold sensitivity is different from person to person, so the exact temperature that triggers symptoms varies, for some it’s a winter wind, for others an air-conditioned room or an icy drink.

Why Cold Urticaria Happens: Causes and Risk Factors

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. It can appear out of nowhere and start at any age, adds Dr. Ryan.

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

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

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

Is Cold Urticaria an Autoimmune Disease?

Not exactly, but the two can be connected. Cold urticaria itself is a physical form of hives, not an autoimmune disease. In some people, though, it can be associated with autoimmune activity or other underlying conditions, which is one reason an allergist may recommend blood tests to look at the bigger picture.

Do your hives come with lingering fatigue, joint pain, or other symptoms? 

Don’t wait. Get an evaluation today.

Cold Urticaria Symptoms

Hives (red, itchy welts) can appear within minutes of cold exposure, or as your skin warms back up, and may last from 30 minutes to a couple of hours, Dr. Ryan says. Common symptoms include:

• Red, itchy welts or hives where skin was exposed to cold
• Burning or itching as the skin rewarms
• Swelling (angioedema) of the lips, tongue, throat, or eyelids
• Reactions after cold drinks, cold water, or handling cold objects

In extreme cases, cold urticaria can lead to anaphylaxis, says Sharlene Llanes, MD, an allergist and immunologist at AllerVie Health in Loxahatchee, Florida.

How Cold Urticaria Is Diagnosed: The Ice Cube Test

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. An allergist places an ice cube on the skin to see whether hives develop in a controlled setting. “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.”

Doctors also commonly diagnose the condition from your history and symptoms. “Most patients come in with a very clear story linking their hives to cold exposure,” Dr. Singla says. An allergist may also order skin allergy testing or blood tests to rule out other conditions, such as autoimmune diseases, Dr. Llanes adds.

When to Worry About Cold Urticaria

Most cases aren’t dangerous. But allergist and immunologist specialist Dr. Ryan says to seek urgent medical attention if you have any of these symptoms:

• Dizziness
• Shortness of breath
• Fainting
• Swelling of the tongue or throat
• Vomiting or 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 fade, if other symptoms (like pain or fatigue) linger, see your primary care doctor. You may need to be evaluated for another condition, such as an autoimmune disorder or blood disorder, Dr. Singla says.