Cold Allergies

As we enter into the Winter months, a sensitivity to cold temperatures may trigger some allergic reactions in susceptible individuals. Below are some conditions where exposure to cold can cause clinical disease.

Cold-Induced Urticaria:

Exposure of the skin to cold temperatures can be a trigger for breaking out in hives. Cold-induced hives (i.e., urticaria) typically manifest themselves as intensely itchy, red raised blotches (i.e., welts) of various shapes and sizes over the exposed skin. The hives usually begin to develop within 5 to 10 minutes after the exposure to cold, usually when the skin is rewarming. This condition (i.e., cold-induced urticaria) is usually noticed after returning indoors from cold temperatures outdoors or after swimming and coming out of a cold water pool. The hives generally last for about 1 to 2 hours.

More severe cases of cold sensitivity may also result in anaphylaxis, a life-threatening condition in which in addition to hives one may also experience systemic symptoms such as nausea, dizziness, difficulty in breathing, and/or fainting. This condition is referred to as cold-induced anaphylaxis. Certain viral infections are thought to play a role in the etiology of this disorder.

The diagnosis of cold-induced urticaria or cold-induced anaphylaxis entails comprehensive history taking, a physical examination, and an “ice cube test.” This involves placing an ice cube in a plastic bag over the skin and keeping it in place for approximately 10 minutes before removing it. As the skin rewarms, an itchy, red, welt appears on the skin in the shape of the ice cube with slightly raised edges. A positive ice cube test confirms the diagnosis of cold-induced urticaria.

Treatment of this condition involves avoidance of the exposure to cold temperatures at all times. Bundling up before venturing out into cold weather and checking the temperature of water before swimming are helpful in preventing acute episodes. Avoidance of drinking cold beverages may also be helpful in certain patients.

When avoidance to the exposure of cold is not possible or practical, taking antihistamines can minimize the severity of symptoms. Periactin (i.e., cyproheptadine) is a first generation antihistamine that has been proven to be beneficial in this condition.

A recent study in 2019 found that a “biologic” medication named Xolair (i.e., omalizumab) was also effective in preventing cold-induced hives when taken as a subcutaneous injection every 4 weeks.

Individuals with a history of cold-induced anaphylaxis should be trained in the proper technique of using an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) and carry it at all times. It is available at most pharmacies in various brand names and requires a prescription from a physician. It should be noted that an individual should go to the nearest emergency room immediately if the self-injectable epinephrine device was used.

Many patients with cold-induced urticaria notice that their symptoms usually become less frequent and less severe after 5 to 10 years.

Familial Cold Autoinflammatory Syndrome:

Familial cold autoinflammatory syndrome (FCAS), also known as familial cold urticaria, is a rare, inherited inflammatory disorder characterized by occasional episodes of rash, fever, joint pain, and/or other signs or symptoms of systemic inflammation triggered by the exposure to cold. The onset of FCAS occurs during infancy and early childhood and persists throughout the patient’s life.

Other symptoms may include profuse sweating, drowsiness, headache, extreme thirst, red eyes, blurred vision, eye pain, watering eyes, nausea and/or vomiting.

Symptoms typically occur within hours after exposure to cold. In most cases, a rash will occur within the first 1-2 hours, followed by a fever and joint pain. Episodes usually last for less than 24 hours.

The treatment of familial cold autoinflammatory syndrome may include non-steroidal anti-inflammatory drugs (NSAIDs) which are often used to alleviate joint pain. High doses of corticosteroids have shown to be somewhat effective, but may cause short and long-term side effects.


Chilblains is a vascular condition in which the very small blood vessels become inflamed when exposed to cold air. Symptoms may include red skin, itching, pain, blistering, and/or swelling. These symptoms usually resolve within a few weeks, especially if the weather gets warmer.

Raynaud’s Disease/Phenomenon:

Raynaud’s disease primarily affects the fingers and toes. It usually occurs when an individual is exposed to the cold. Individuals with this condition have blood vessel constriction that causes an interruption in the flow of blood to their extremities.

Symptoms may include pain and paleness or blueness of the skin in the affected areas following exposure to cold temperatures. Symptoms may last minutes or hours. This disorder may be associated with other underlying conditions such as connective tissue disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus), smoking, certain medications (e.g., high blood pressure medications, ADHD medications, hormones), certain foods (e.g., caffeine), and carpal tunnel syndrome. If no associated underlying condition is found, it is referred to as Raynaud’s phenomenon.

Cold Agglutinin Disease:

In individuals with cold agglutinin disease, the body attacks its red blood cells in response to their blood temperature falling to a lower temperature than their regular body temperature.

This condition can result in hemolytic anemia (i.e., a disorder where one’s red blood cells are destroyed faster than they are made). It’s often associated with mycoplasma pneumonia infection, scarlet fever, staphylococcal infections, and rheumatological conditions.

Paroxysmal Cold Hemoglobinuria:

Paroxysmal cold hemoglobinuria is a rare autoimmune disorder usually seen in children in response to cold exposure after an infection. It mainly affects the hands and feet. The symptoms may include dark brown colored urine (due to blood pigment), fever, anemia, abdominal pain, and difficulty in breathing. The condition has been linked to secondary syphilis, tertiary syphilis, and other viral or bacterial infections.

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding your hives (i.e., urticarial), allergies, and/or asthma.  We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  In addition, the Washington, DC and McLean, VA offices are accessible by Metro.  We also have a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  Please make an appointment by calling any one of our 3 offices, or alternatively, you can click Request an Appointment and we will answer you within 24 hours by the next business day.  Black & Kletz Allergy diagnoses and treats both children and adults and we are proud to serve the Washington, DC metro area, which we have done for more than 5 decades.