Q: “I experience hives whenever I go outside in freezing weather or dip into cold water. What can I do?”

Janna Tuck, MD: You likely have what’s called cold urticaria, in which the stimulus of cold releases histamine into the body and causes hives and swelling. Cold urticaria symptoms occur soon after the skin is exposed to cold temperatures or cold water.

The condition is mostly not serious but severe reactions, or anaphylaxis, do occur – typically when the whole body is impacted by cold, such as when swimming in cold water. This can cause a drop in blood pressure, fainting and even death. Swelling of the tongue or throat can lead to difficulty breathing.

To prevent symptoms, it’s obviously important to avoid cold temperatures and cold water. If you live in a cold weather area of the country, stay indoors as much as you can when temperatures dip. Don’t go swimming in cold water. Avoid the freezer section at the grocery store if you have severe symptoms.

There’s no set temperature that can cause symptoms. Patients with cold urticaria have different thresholds. For some it has to be below freezing, but for others it’s cool weather. If symptoms are severe or impacting your quality of life, or if you experience other non-skin symptoms along with cold urticaria, then it’s time to consider seeing a specialist such as a board-certified allergist.

Q: What is the treatment? Should I carry an epinephrine auto-injector?

Dr. Tuck: For most patients, antihistamines should clear up hives. Antihistamines can also be helpful with managing the condition; when patients know they will be exposed to cold, taking an antihistamine can help the body better tolerate it.

Cold urticaria patients typically won’t need an epinephrine auto-injector unless they are at risk for a severe reaction, or anaphylaxis. Epinephrine is the only medication proven to stop anaphylaxis.

I’m an allergist in Missouri and it doesn’t get extremely cold here, so if a cold urticaria patient only experiences hives, I would prescribe an epinephrine auto-injector only if it’s requested, or if the patient is worried his or her airways could swell as a result of a reaction. Allergists in colder parts of the country may have a different approach.

Q: How do allergists test for cold urticaria?

Dr. Tuck: We test for it by taking an ice cube, wrapping it up in plastic, and placing it on the skin for a short period of time. If it’s cold urticaria, a hive will pop up.

Some rare diseases are associated with cold urticaria. Talk with your allergist if your symptoms are accompanied by joint pain or fever following exposure to cold. It’s important to provide a detailed history of your symptoms, including family history, to the allergist for a complete diagnosis.

Janna Tuck, MD, FACAAI, is a board-certified allergist and immunologist with Allergy Partners of Cape Girardeau in Missouri. She serves as spokesperson for the American College of Allergy, Asthma & Immunology (ACAAI).

Have a medical question? Email editor@allergyasthmanetwork.org or write to Ask the Allergist, Allergy & Asthma Network, 8229 Boone Blvd., Suite 260, Vienna, VA 22182.

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