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BLOG: Cold urticaria
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Read more from Mark R. Levine, MD.
Cold urticaria is not very common but should be recognized following oculoplastic surgery.
I was recently about to do bilateral ptosis surgery on a patient who informed us preoperatively that she has cold urticaria and that cold makes her face swell and she gets significantly large welts on her skin. With that in mind, we made sure the room was warm, the IV solutions were at room temperature, a blanket was placed over the patient, and IV antihistamines were administered. Postoperatively she had no compresses and no reactions.
Cold urticaria is an unrecognized and potentially serious cause of postoperative swelling. It may be familial or acquired and characterized by the development of hives, welts and/or angioedema following cold exposure. Primary acquired cold urticaria is nonfamilial and can be divided into three subtypes: localized urticaria; generalized reactions, without the development of hypotension, and systemic reactions, with hypotension; and/or airway compromise. There is a secondary acquired cold urticaria, which may be caused by cryoglobulinemia, that can be primary or secondary to malignancies.
We are all familiar with postoperative swelling secondary to poor tissue handling, excessive cautery and lymphatic disruption. Further contributing factors may be elevated blood pressure at the time of surgery or excessive bleeding during the surgery. However, progressive postoperative periorbital swelling may be something else, especially within the first 24 hours postoperatively. The combination of hives, welts or angioedema following cold exposure should make one consider cold urticaria. The hives vary in size from 7 mm to 27 mm. The welts are usually itchy. Hands and feet may be involved and are swollen. This should not be confused with an allergic reaction to topical medications, which generally take a little more than 24 hours to develop.
The diagnosis of cold urticaria is made by a history of cold-induced reactions, a positive cold stimulation test and exclusion of systemic diseases.
The cold stimulation test can confirm the diagnosis of primary acquired cold urticaria by placing ice in a plastic bag on the patient’s forearm for a minute. After the ice is removed, the exposed area is observed for 5 minutes for the development of a wheal and flare reaction. If there is no response, the test is repeated at a different location in an increasing longer interval of 3 to 5 minutes and for up to 10 minutes to see if there is a reaction.
Treatment, as mentioned above, is warming the patient and stopping the cold compresses. Antihistamines may be given orally; however, in severe reactions, injectable epinephrine may be necessary.
In summary, although this syndrome can be benign and self-limited, some people may react significantly, and therefore it needs to be recognized and appreciated.