Acquired Cold–Induced Urticaria in Pediatric Patients: A 22-Year Experience in a Tertiary Care Center (1996–2017)

Abstract

To describe 2 decades of experience evaluating and managing pediatric acquired cold-induced urticaria (ACU).The study included 415 children and adolescents (aged 4 months to 18.3 years at diagnosis) with ACU evaluated at Boston Children’s Hospital from 1996 to 2017.Three authors used a retrospective electronic medical record review of visits coded for urticaria or temperature-induced urticaria to identify patients <19 years of age diagnosed with ACU on the basis of history of urticaria, angioedema, and/or anaphylaxis with cold exposure.Most patients were atopic (78%), but only a minority (26%) had urticaria associated with other triggers. Anaphylaxis was described in 19% of the cohort, with the majority of anaphylaxis triggered by swimming (78%). Repeat episodes of anaphylaxis were described in 7% of patients. Cold stimulation testing (positive in 70% of those tested) was associated with anaphylaxis risk; however, 12% of those with negative cold testing results still experienced anaphylaxis. Disease resolution, seen in 9% (at a median age of 10 years), was more likely in those without anaphylaxis.Children and adolescents with cold urticaria are likely to have other allergic disease (such as allergic rhinitis, asthma, food allergy, atopic dermatitis, and oral allergy syndrome). The risk for anaphylaxis is significant, as is the chance of spontaneous resolution. Negative results of cold stimulation testing do not exclude anaphylaxis risk. Patients and families should be counseled regarding the risks of swimming, and epinephrine prescription is appropriate.This article follows a previous report from the same group, which described similar findings in 2004, with practical findings for patient management. ACU is uncommon, with an estimated incidence of 0.05%. The authors of this report deliver several important take-home messages: (1) ACU carries real risk for anaphylaxis; (2) counseling should address risks of swimming and other cold exposures; (3) prescribing epinephrine autoinjectors is appropriate for patients with ACU; (4) the ice cube test cannot be used to exclude anaphylaxis risk; (5) disease resolution is less likely in patients with anaphylaxis; (6) patients with ACU have greater risks of asthma, rhinitis, eczema, and food allergy; and (7) nearly 10% of children and adolescents may outgrow this diagnosis in time.