Combined cold urticaria and cholinergic urticaria--clinical characterization and laboratory findings

Pure Cold-Induced Cholinergic Urticaria in a Pediatric Patient

Cold urticaria and cholinergic urticaria are two distinct entities. The presentation of exclusive cold-induced cholinergic urticaria is very rare. The patient described herein had experienced urticaria in the exclusive setting of exercising in a cold environment. Urticarial testing including laboratory and in-office testing was all negative. The patient has prevented urticaria symptoms with oral antihistamine therapy. Pure cold-induced cholinergic urticaria is rarely described in literature. This form of urticaria has yet to be described in a pediatric patient.

Cholinergic urticaria: More than a simple inducible urticaria

BACKGROUND

Cholinergic urticaria (ChU) is characterized by small wheals induced by an elevated core temperature. Its pathomechanism and various aspects of its clinical manifestations are still poorly understood. This study aimed to evaluate the spectrum of symptoms and signs of ChU in Korean patients.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with ChU.

RESULTS

Among 203 patients (188 male and 15 female), 29 (14%) complained only of an itching or burning sensation without visible skin eruption. The prevalence of ChU was highest in patients in their twenties (56%), while most patients first developed their symptoms during their teens (65%). Patients with a visible skin eruption showed better responses to antihistamines than those without skin lesions.

CONCLUSIONS

Physicians should consider the varying manifestations of ChU, including cholinergic pruritus and erythema as minor variants, to provide better management of ChU.

The association of cholinergic and cold-induced urticaria: diagnosis and management

Physical urticaria is often challenging to diagnose and manage. We present a case of both cholinergic and cold-induced urticaria and discuss the diagnosis and management strategies of these two important conditions.

Clinical characteristics of cholinergic urticaria in Korea

BACKGROUND

Cholinergic urticaria is a type of physical urticaria characterized by heat-associated wheals. Several reports are available about cholinergic urticaria; however, the clinical manifestations and pathogenesis are incompletely understood.

OBJECTIVE

The purpose of this study was to investigate the clinical characteristics of cholinergic urticaria in Korea.

METHODS

We performed a retrospective study of 92 patients with cholinergic urticaria who were contacted by phone and whose diagnoses were confirmed by the exercise provocation test among those who had visited The Catholic University of Korea, Catholic Medical Center from January 2001 to November 2010.

RESULTS

All 92 patients were male, and their average age was 27.8 years (range, 17~51 years). Most of the patients had onset of the disease in their 20s and 30s. Non-follicular wheals were located on the trunk and upper extremities of many patients, and the symptoms were aggravated by exercise. Eight patients showed general urticaria symptoms and 15 had accompanying atopic disease. Forty-three patients complained of seasonal aggravation. Most patients were treated with first and second-generation antihistamines.

CONCLUSION

Dermatologists should consider these characteristics in patients with cholinergic urticaria. Further investigation and follow-up studies are necessary to better understand the epidemiological and clinical findings of cholinergic urticaria.

New concepts of hive formation in cholinergic urticaria

Patients with cholinergic urticaria (CU) show a number of small, short-lasting hives when their body core temperature increases, usually during sweating following exercise or bathing. The precise mechanism(s) of hive formation in CU has been unclear except for the involvement of acetylcholine. We recently reported that most CU patients show immediate-type skin responses to their own sweat, whereas the rest of CU patients have positive autologous serum skin tests (ASSTs). The former group produced satellite wheals following acetylcholine injection, whereas the latter group produced hives in conjunction with hair follicles. We propose two subtypes of CU: 1) a sweat-hypersensitivity type with strong hypersensitivity to autologous sweat, nonfollicular hives, development of satellite wheals, and lack of positive ASST; and 2) a follicular type with follicular hives and positive ASST, but no hypersensitivity to autologous sweat or satellite wheals. We discuss the mechanisms of hive formation in these subtypes.

Mizolastine in primary acquired cold urticaria

BACKGROUND

Treatment of primary acquired cold urticaria (CU) is quite difficult because of variable clinical effectiveness and side effects of classic antihistamines.

OBJECTIVE

The objective of the study was to assess the efficacy and safety of mizolastine, an antihistaminic with antiallergic properties, versus placebo in primary acquired CU.

METHODS

This study was a phase II, multicenter, randomized, double-blind, crossover, placebo-controlled study of mizolastine (10 mg, once daily) versus placebo in 28 patients with primary acquired CU. Efficacy was measured by the cold-stimulation time test, the wheal response, and pruritus intensity after an ice-cube test.

RESULTS

Mizolastine delayed the cold-induced wheal reaction, reduced wheal response at 3 and 10 minutes, and reduced pruritus intensity. Statistically significant differences were observed versus placebo for the cold-stimulation time test, wheal response at 3 and 10 minutes, and pruritus intensity (P =.006,.015,.009, and.005, respectively). No clinically relevant adverse events were reported.

CONCLUSIONS

Mizolastine (10 mg, once daily) was shown to be superior to placebo for both delaying and reducing the cold-induced wheal reaction without significant adverse events. Results suggest that mizolastine may be effective in the treatment of CU.

An unusual reaction to cold: a sporadic case of familial polymorphous cold eruption?

A 14-year-old Japanese girl had a lifelong history of skin lesions developing after generalized exposure to cold air; the lesions were often accompanied by systemic symptoms such as fever and chills. The skin lesions were non-pruritic, maculopapular, erythematous eruptions and were neither urticarial nor angioedematous. An ice-cube test was negative. Laboratory examinations showed marked leucocytosis during an acute attack. On the basis of clinical features, histological findings and laboratory data, although these symptoms were sporadic, the most likely diagnosis was familial polymorphous cold eruption, which has also been referred to as familial cold urticaria. Serum levels of granulocyte colony-stimulating factor and interleukin 6 were significantly elevated during an acute attack after cold exposure, suggesting that both cytokines played important parts in the development of her condition.

Preventing, Diagnosing, and Treating Cold Urticaria

In brief While most cases of cold urticaria are mild and characterized only by pruritus, severe anaphylactic reaction is possible. Our patient, a healthy male runner, experienced intermittent and sometimes severe pruritus and severe urticaria after running in the cold. Avoiding cold air and cold water or using prophylactic medications that suppress the release of mast cell mediators has proved modestly successful in preventing and treating cold urticaria. Patients who develop cold urticaria often improve with time.