Cold Urticaria Causes, Treatments, and Diagnosis

Hives in the Cold

Cold urticaria results from exposure to cold environments.

People who have a physical urticaria have a physical trigger for their hives, such as pressure, heat, cold, sunlight, water, or exercise. Up to 30 percent of people with chronic urticaria have a physical cause for their urticaria.

What Is Cold Urticaria?

Cold urticaria is a form of physical urticaria that is characterized by the development of hives and swelling with cold exposure.

A variety of cold triggers can cause symptoms in 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 aquatic activities involving cold water. Cold urticaria may also be caused by a number of underlying medical problems, including a variety of infections, autoimmune diseases, some cancers, and side effects from certain medications. There are also forms of cold urticaria that run in families.


The diagnosis of cold urticaria is made with an ice-cube test. This test involves the placement of an ice-cube (or other cold objects such as a cold freezer pack) on the forearm. The cold object is left on the arm for up to 10 minutes, with a positive test showing the appearance of a hive or swelling at the site within 5 minutes after removal of the cold object.

The amount of time of exposure to the cold object that it takes can predict the severity of the disease; a positive test with shorter exposure times are associated with more severe symptoms.

Some forms of cold urticaria may not have a positive ice-cube test. These include:

Delayed cold urticaria, with symptoms occurring 12 to 48 hours after cold exposure.

The ice-cube test may show a positive result many hours after placement in these people.

Cold-dependent dermatographism, where symptoms only occur with rubbing or pressure on the cold skin. The site of the ice-cube test may show a hive if rubbed with a blunt object, such as a pen.

Cold-induced cholinergic urticaria, with symptoms, usually occurring with exercise in cold environments. If symptoms also occur with exercise in warm environments, it is more likely that a person has cholinergic urticaria.

Localized cold reflex urticaria leads to symptoms of hives and swelling away from the area of direct exposure to cold. An ice-cube test on the arm may cause hives to form a few inches away from the site of ice-cube application, for example.

Once someone is diagnosed with cold urticaria, it may be necessary to look for underlying causes of the disease. This may include blood tests to evaluate for autoimmune diseases, cancers (such as leukemia), infections (such as mononucleosis, viral hepatitis, and syphilis), as well as reviewing the medications being taken. Medications such as penicillin (and related antibiotics), birth control pills, and certain anti-fungal medications (such as griseofulvin) have been reported to cause cold urticaria.


Avoidance of cold environments, particularly swimming in cold water, is 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. People with severe symptoms should carry an injectable epinephrine and wear a Medic-Alert bracelet. Symptoms may be decreased with the use of various antihistamines, particularly the older, sedating antihistamines such as cyproheptadine.


Wanderer AA. The Spectrum of Cold Urticaria. Immunology Allergy Clinics North America.1995;15(4):701-23.

Kaplan AP. Urticaria and Angioedema in Allergy: Principles and Practice. 5th Edition, edited by Middleton E, et al. Mosby publishing, St Louis, MO. 1998:1104-22.