What is Cold Urticaria?

 Cold urticaria is an allergic reaction to exposure to cold that produces hives and  swelling. There is a large variety of triggers that can set off this type of reaction for  people with this syndrome, including cold weather, cold food and drinks, as well as  swimming in cold water. While most people with cold urticaria experience only mild  symptoms of itching and hives with cold exposure, some people have experienced  life-threatening anaphylaxis with rapid exposure to cold water.

 The hives are produced by a rapid release of histamine brought about by IgE antibodies  and eosinophils (the types of antibodies and white blood cells often involved in allergic  reactions) in response to the cold. Rapid cooling, as from the evaporation when one  gets  out of a swimming pool, can trigger cold urticaria even on a warm day. For people  with  cold urticaria, swimming in very cold water is quite dangerous, and can cause a  massive  release of histamine resulting in low blood pressure, fainting, shock, and even  death.

 Diagnosis

 How would a doctor be able to tell if your child has cold urticaria? They will usually use  the “ice cube test.” Cold urticaria is diagnosed by holding an ice cube against the skin of  the forearm for 1 to 5 minutes. A distinct hive should develop if a patient has cold  urticaria. This is different than the normal redness that would be seen in people without  cold urticaria.

 Treatment

 Avoid rapid changes in temperatures, particularly swimming in cold water, are an  important way to prevent symptoms in people with cold urticaria. Those with cold  urticaria should never swim alone, given the potential for severe anaphylaxis with cold  water exposure, and therefore a risk of drowning. It also may be necessary to avoid cold  foods, such as ice cream and cold beverages. You should also be watching for rapid  cooling from sweat – a hot day does not exempt a cold urticaria reaction! 

 People with severe symptoms should carry and injectable epinephrine (Epi-pen) and  wear a Medic-Alert bracelet. Symptoms may be decreased with the use of various  antihistamines, particularly the older, sedating antihistamines such as cyproheptadine.  Anielei takes Zyzal everyday and that has really helped reduce her reactions.

 Chronic Urticaria

 Chronic Hives

 Definition

 Hives, also known as urticaria, are batches of raised, red or white itchy welts (wheals)  of various sizes that appear and disappear. While most cases of hives go away within a  few weeks or less, for some people they are a long-term problem. Chronic hives are  defined as hives that last for more than six weeks or hives that go away but recur  frequently. If your hives keep coming back – they’re chronic!

 Causes

 In most cases of chronic hives, a cause is never clearly identified. In some cases, the  condition may be related to an underlying autoimmune disorder — when your body  becomes allergic to itself. Chronic hives can also be linked to other health problems such  as thyroid disease or lupus.

 Treatment

 For many people, a combination of antihistamine medications provides the best relief.  Try to figure out the general environment that produces a reaction and then avoid or l  limit exposure. There are alternative diets which have been reported to reduce histamine  production. You can get more information here: (link to article).

 Cholinergic Urticaria

 
 Cholinergic urticaria Heat urticaria is a subcategory of physical urticaria (aka hives) that  is a skin rash brought on by a hypersensitive reaction to body heat. Hives are caused by  any increase in body temperature, such as hot showers, exercise, spicy foods, or being  under too many covers in bed at night. Strong emotions may also cause hives to occur  in people with cholinergic urticaria. The hives in cholinergic urticaria are classically  pin-point in size, less than the size of a mosquito bite. These may group together, or  coalesce, into larger hives over time. Anielei has both cold urticaria and cholinergic or  heat urticaria.

 Cholinergic or heat urticaria is a form of chronic hives that is caused by an increase in  body temperature. The visible hives (sometimes called heat bumps) appear as a  multitude of small 2-3 mm welts typically surrounded by patches of red skin. The  affected area will often feel warm and can be extremely itchy or exhibit a burning  sensation. Typically the rash occurs on the upper trunk and the arms but can appear on  other parts of the body. The rash may be worse in areas where clothing restricts the  skin's ability to cool itself such as hat brims, waist bands, tight collars, backpack straps,  etc. This can be compounded since many people with cholinergic urticaria also have  pressure urticaria, in which pressure on the skin causes a reaction – never an easy  diagnosis, is there?

 The rash typically develops within a few minutes of a rise in body temperature but can  take longer to appear visibly on the skin. Usually before you even see the rash you will  get a general warming of the skin or itchiness – especially itchiness. Before Anielei  started taking antihistamine, she was constantly itchy. The hives last from a half an  hour to several hours with the duration usually depending on the severity of the  outbreak.

 Cholinergic urticaria is a fairly common type of hives and is often seen together with  other forms of urticaria, especially chronic urticaria. People who have other atopic  conditions such as eczema (atopic dermatitis), allergic conjunctivitis, allergic rhinitis or  asthma generally have a higher susceptibility to urticaria symptoms. Other allergic  conditions, such as asthma can sometimes be triggered by a urticaria attack. 

  Often it is handled just with limiting one's exposure to triggers such as strenuous  exercise or heat. For some, the reaction can be limited by making sure to wear light  breathable clothing allowing the body to remain cool. Also, gradually warming the body  with light exercise first can help limit the effects in some people. Since an attack can  often be felt coming on, it can sometimes be halted by rapid cooling, such as applying  cold water or an ice pack to the skin – unless you also have cold urticaria! Exercising  consistently to break a sweat before cold weather and throughout the winter  significantly reduces the symptoms in many cases.

 How is Cholinergic Urticaria Treated?

 Cholinergic urticaria can be very difficult to treat. Most treatment plans for cholinergic  urticaria involve knowing your own triggers, but this can be difficult since there is often  comorbidity (occurs together) with other forms of urticaria and some urticaria is  idiopathic – which just means they can’t figure out what is causing it, so treatment can  mean a lot of trial and error.
 
 The best treatment for cholinergic urticaria is antihistamines. While any antihistamine is l  likely to be helpful, older antihistamines, such as hydroxyzine, seem to work especially  well, however, does have the side effect of sleepiness.  Anielei takes the antihistamine  Zyzal daily, for all her forms of urticaria and it seems to help her quite a bit.

 Severe cases of cholinergic urticaria have been successfully treated with danazol, which  is an anabolic steroid. Use of this medication is limited by its severe side effects,  however, and if you are talking about a young child (Anielei Rose is only 5), it is my  opinion (as a father) that you really want to stay away from anabolic steroids, if at all  possible, but medication is definitely something to be carefully worked out with your  primary  care doctor and allergist or immunologist.

 Types and differences of hives

 Just to complicate things, there are many different kinds of classifications of Urticaria. It  is often classified according to the cause and/or length of time the hives last. Examples  include:

• Acute urticaria. Episodes of hives that last for less than six weeks. Most episodes of allergic hives are acute and persist for a few days after exposure to the allergen.
• Aquagenic urticaria. Hives caused by contact with water.
• Cholinergic urticaria. Hives caused by exercise, passive body warming (shower or bath) or emotional stress. The wheals (individual hives) usually occur around the lips or larynx, although they can appear anywhere on the skin. These hives are generally the smallest type seen, appearing on the skin like goosebumps. This allergic reaction can also lead to lung symptoms, such as shortness of breath.
• Chronic idiopathic urticaria. Episodes of hives that persist for more than six weeks (chronic) for which the cause is unknown (idiopathic). Seen most often in middle-aged women, but can affect all ages, genders and races. Chronic, idiopathic urticaria can persist for years and has been traditionally believed to be nonallergic. However, recent research indicates that some patients develop an allergy to components in their own skin, continuously triggering hives. Researchers hope their findings will lead to better understanding of the causes of chronic idiopathic urticaria.
• Cold urticaria. Hives caused by cold temperatures.
• Contact urticaria. A form of allergic urticaria caused when the skin comes in direct contact with an allergen (e.g., in a person with a latex allergy, it may be caused by wearing latex gloves).
• Pressure urticaria. Hives caused by pressure on the skin. There are two main forms: Dermatographism involves wheals that form in areas where clothing applies friction to the skin. Delayed pressure urticaria involves wheals that form under belts, shoulder straps or bras and are more diffuse in appearance.
• Solar urticaria. Hives caused by direct exposure to the sun. Wheals may appear within minutes of sun exposure (photosensitivity).
• Vasculitic urticaria (urticarial vasculitis). Hives that stay in the same place for more than a day and that leave a pigmented bruise mark when the swelling has resolved. Vasculitic urticaria may be part of an illness, such as rheumatoid arthritis, which also affects other parts of the body.
• Exercise-induced anaphylaxis. A related condition, which may be triggered by a combination of physical exertion and the eating of certain foods. It is differentiated from cholinergic urticaria by the structure of the lesions and the degree of response to passive body warming.

 Anielei Rose

 These different types of hives often occur together, making it even harder to get a  good diagnosis. For instance, cold urticaria and pressure urticaria often occur together.  My daughter, Anielei Rose, has chronic urticaria including both cold urticaria and  cholinergic urticaria. She is currently taking daily antihistamine and it has really helped  keep her reactions under control. Being very mindful of temperature changes and how  she is dressed is now just a part of life. Even Anielei will tell you that “the doctor says I  have to get used to the water gradually!”
 
   

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