I VIVIDLY remember the first time it happened. I was 9 years old, and walking to school in Calgary on a chilly October morning. Although my mother had set out my winter coat and hat, I sneaked out of the house wearing only a light jacket. I was cold, and soon my face started to feel funny.
I felt bumps on my cheeks, but didn’t think too much of this until I reached the playground. “What’s wrong with your face?” a boy in my class demanded loudly.
Suddenly, kids crowded around staring and questioning. I buried my face in my hands. This, it would turn out, was my first outbreak of cold-induced urticaria – or hives and swelling brought on by exposure to cold conditions.
From then on, chilly weather came to mean anxiety and restrictions. While I had no formal diagnosis, the family doctor’s orders were simply to avoid the cold. My parents’ over-protectiveness kicked into high gear, and my winter activities became slim pickings. No more ice skating or tobogganing and, even with the Rocky Mountains a stone’s throw away, I could forget about skiing.
Things didn’t improve with teendom. The gawking and ridicule I had to endure when I broke out in hives during outdoor gym class or a fire drill were horrifying to an adolescent.
And we’re not talking little dot hives; I got big welts all over my body. I spent hours concocting excuses for not going out in the cold or developing escape routes and backup plans in case it turned cold.
It wasn’t until I was an adult, and with the advent of the Internet, that I was able to find some answers, and have another doctor make a firm diagnosis. Following years of suffering and avoidance, finding a management plan that worked for me was a complete revelation.
Identifying the Culprit
Part of the problem with getting a diagnosis is that cold-induced urticaria is a relatively rare condition. Experts say it accounts for only 3 per cent of chronic urticaria cases.
There are two forms of cold-induced urticaria; the first is “familial”, a disorder that runs in a family’s genes and emerges in infancy. The second, more common form is “acquired”. It is not genetic, and cases have occurred in babies as well as senior citizens.
Acquired is further divided into primary or idiopathic – the latter literally meaning “unknown cause”. Dr. Martin Ostro, a professor with the division of allergy and inflammation at Harvard University’s Beth Israel Deaconess Medical Center in Boston, explains that in “90 per cent of cases, there is no underlying cause demonstrated.”
In other words, while the experts know that cold triggers these reactions, they can’t say why people like me develop the condition.
I had assumed I was simply “allergic to the cold”. But cold-induced urticaria is not a typical allergy in that there is no specific IgE, the allergic antibody, which responds to a particular substance.
For instance, with a peanut allergy, there is a measurable level of IgE in the patient’s blood that specifically recognizes peanut protein.
Ostro says one theory suggests that cold-induced urticaria occurs because the IgE made by people with this condition is abnormal and changes shape on being cooled and re-warmed. This shape change stimulates the IgE receptor and leads to the release of histamine, resulting in itching, redness and hives.
To test for cold-induced urticaria, an allergist starts by reviewing a patient’s history – whether there have been incidents of hives on exposure to cold; swelling and itching of the throat on drinking of cold liquids; or generalized itching, redness and swelling after swimming in cold water.
If so, the doctor may employ an ice-cube test, placing ice on the underside of the patient’s forearm for five minutes. In a positive test, the area will turn red, itchy and start to swell, forming a hive as it warms over the next 10 minutes.
Though my hives can get itchy and painful, I’ve found cold-induced urticaria to be largely socially crippling. However, it can be a life-threatening condition for others, who must take extreme care, avoiding, for example, swimming in cold water.
The good news is, with proper diagnosis, most of us with cold-induced urticaria can be taught to control the condition. A good management plan can keep hives at bay, or decrease the frequency and intensity.
“This not only makes the patient’s life more pleasant,” says Ostro, “but it can prevent potentially life-threatening reactions such as swelling of the throat or total body swelling with a drop in blood pressure.”
Reacting to Reactions
Coping comes down to knowing what sets off your reactions. Ostro advises that sufferers “become familiar with triggers such as air temperature and amount of time you can stay outside at particular temperatures, and food temperatures, which can cause throat swelling.
By working out specifics, the patient has a much better idea of what will precipitate hives, and they are not constantly surprised.” That means determining the amount of clothing needed to prevent hives, steering clear of ice in drinks, and minimizing or completely avoiding foods that are cold.
I’ve never experienced swelling with cold food but, for others, it can be potentially fatal.
“Some people react at higher temperatures, but everybody with cold-induced urticaria should be careful about very cold food,” Ostro cautions. “There is always a potential swelling in the throat if enough is ingested.”
As well, “cold-induced urticaria does wax and wane in severity, but most patients have it on a chronic basis,” says Ostro. While I’ve had fewer outbreaks as an adult, that could be the result of my management plan instead of a reduced severity in my condition.
Still, since weather is beyond our control, cold-induced urticaria is challenging to manage.
There are times I’ve reacted in warm weather simply because I got chilled. Avoiding exposure to cold is not always possible. This is where medications come in.
“There is no cure for cold-induced urticaria, but administering antihistamines, for example, Benadryl or Zyrtec, can prevent or greatly reduce the severity,” says Ostro. If a patient has a history of internal hives in the mouth and throat that cause difficulty breathing, he will prescribe an epinephrine auto-injector.
Ultimately, Ostro recommends working with your physician to find the medication regime that optimally controls the condition.
For me, Zyrtec (called Reactine in Canada) does the trick. I take it ahead of time whenever I plan to be outdoors in cool weather for an extended period. But it also works in a pinch if the weather suddenly turns – though a few hives may develop before the medicine takes full effect.
As weather in Alberta is wholly unpredictable, I always carry my antihistamines, and an extra sweater or jacket. If I’m going to be outdoors for a while, I’ll pack extra socks and a hat. Plus, I try to make sure there’s somewhere that I can go to warm up, even if that’s just to my car.
Understanding cold-induced urticaria has given me the confidence to cope with it. Now when I have a reaction, I know how to respond, and how to explain to others what is happening.
At the age of 30, I no longer feel the trauma of my youth. What’s better, and harder to convey, is just what it feels like to enjoy the cold climate in which I’ve lived my whole life.
It is incredibly freeing to do simple things like walking my dog without worrying about getting hives. I can finally take part in a winter sport or a good snowball fight. At last, Old Man Winter and I have come to terms. I’m sure it’s the beginning of a beautiful friendship.