Hives from the Cold: How Ice Baths, Winter Air, and Chilled Drinks Set Off Cold Urticaria

Cold urticaria is a type of chronic inducible urticaria in which exposure to cold—air, water, or objects—activates skin mast cells and triggers itchy welts (hives) and sometimes deeper swelling called angioedema. In a minority of patients, the reaction can generalize and cause systemic symptoms such as breathing difficulty, light-headedness, or even shock. Swimming in cold water is the most common trigger for severe reactions. ^[1]

Although it can appear at any age, cold urticaria most often affects adolescents and young to middle-aged adults and is about twice as common in women. Population estimates suggest it is rare (about 0.05%). ^[1]

• Local hives and swelling within minutes of cold exposure—ice packs, chilled drinks touching the lips, or stepping into cold air or water. ^[1]
• Systemic reactions can include wheezing, shortness of breath, abdominal pain, a racing or irregular heartbeat, and—rarely—dangerously low blood pressure. These reactions are more likely with whole-body cold exposure, especially sudden immersion while swimming. ^{[1] [2] [3]}

Key point: Reactions after swimming may escalate faster than typical “food allergy”–type events because cold activates a large skin surface area at once. Case series and reports document anaphylaxis triggered by swimming in cold water and even by drinking very cold beverages in sensitized individuals. ^{[2] [4]}

History plus a provocation test confirm the diagnosis.

1. Cold stimulation (“ice cube”) test. A melting ice cube in a thin plastic bag is placed on the forearm for about five minutes. After removal and re-warming, a hive appears within minutes in people with cold urticaria. ^{[1] [5][6]}
2. Critical temperature threshold testing. In specialty clinics, instruments like TempTest apply a continuous temperature gradient (about 4°–44°C) to determine the lowest temperature that provokes hives. Knowing your threshold helps tailor safety advice and track treatment response. ^{[7] [8] [9]}
3. When the ice test is negative but suspicion is high. “Atypical” cold urticaria exists; patients can still have systemic reactions to cold exposure even with a negative ice test, so clinical judgment matters. ^[10]

Your clinician may screen for secondary causes, especially if symptoms are severe or atypical—conditions such as cryoglobulinemia, certain infections, or lymphoproliferative disorders can rarely underlie cold urticaria. ^[1]

Large series indicate that about 1 in 5 patients with cold urticaria experience anaphylaxis, with swimming the most frequent trigger in children and teens. ^{[2] [11]}

Because severe reactions are not rare, major allergy groups recommend considering an epinephrine autoinjector for those at risk. ^[11]

Non-sedating second-generation H1 antihistamines (for example, cetirizine, fexofenadine, levocetirizine, bilastine, loratadine, desloratadine) are first-line. If standard daily dosing is not enough, international guidelines support increasing the dose up to fourfold (under clinician guidance). ^{[12] [13] [14]}

• Omalizumab (targets immunoglobulin E) helps many patients with antihistamine-refractory inducible urticarias, with expert consensus supporting dose escalation (for example, up to 600 mg every two weeks) in select refractory cases under specialist care. ^[15]
• Cyclosporine can be effective in difficult cases when guided by an experienced clinician. ^[16]
• Leukotriene receptor antagonists or other agents are sometimes used as adjuncts in select patients, though evidence is mixed. ^{[1] [16][17]}

Guideline anchor: The 2022 EAACI/GA²LEN/EuroGuiDerm/APAAACI urticaria guideline sets the overall step-up approach: start with second-generation H1 antihistamines, increase the dose up to fourfold if needed, then consider biologics such as omalizumab or other immunomodulators in specialist hands. ^[12]

These go beyond “wear a jacket” and can materially reduce risk.

1. Treat swimming like a graded exposure.

   • Test water first on a small area of skin; enter slowly rather than jumping in.
   • Never swim alone; lifeguard or trained buddy present.
   • Prefer wetsuits in cool water; avoid open-water swims when the air or water is near your personal critical temperature threshold (ask your allergist to measure it).  ^{[7] [1] [2]}

2. Re-think ice baths and cold plunges.

   • If you have a history of cold-triggered hives—or are not sure—avoid cold plunges until formally evaluated. Sudden whole-body exposure can trigger anaphylaxis even in people who have only had “mild” hives before. ^[3]

3. Sip, do not gulp, very cold drinks.

   • Cold beverages can cause local hives around the mouth and, rarely, systemic symptoms. Allow ice drinks to warm slightly, take small sips, and stop immediately if tingling or swelling starts. ^{[4] [1]} 

4. Plan for winter air exposure.

   • Cover exposed skin (face balaclava, scarf over nose and mouth) to reduce airway and facial triggers. Keep an emergency plan if wheeze, throat tightness, or dizziness occur in the cold.

5. Tell the anesthesiologist—well before surgery day.

   • Operating theatres are cool, and intravenous fluids are often room-temperature. Protocols include warming blankets, warmed intravenous fluids, and pre-operative non-sedating antihistamines; staff should avoid histamine-releasing medications when possible. ^[1]

6. Carry an epinephrine autoinjector if you are at risk.

   • Discuss with your allergist. Learn how to use your device and carry it during outdoor winter sports, travel to cold climates, or swim days. ^[11]

7. Freezers, sports coolants, and cryotherapy count as “cold exposures.”

   • Use insulated gloves when handling deep-freezer items; avoid coolant sprays on the skin; do not undergo whole-body cryotherapy unless your allergist clears it.^[1]

8. Know your number.

   • If your clinic measures a critical temperature threshold (for example, reactions below 20°C ), use it: program alerts on your weather app, check pool temperatures, and choose gear (wetsuit thickness, gloves) accordingly. ^{[7] [8] [16]}

9. Special rule for kids and school trips.

   • Ensure teachers and coaches know the diagnosis, triggers, and action plan; avoid cold-water field activities unless fully supervised with immediate access to epinephrine and warm-up gear. Pediatric series show swimming is the leading trigger for severe reactions. ^[2]

• Exercise: Warm up indoors first; avoid outdoor workouts when windchill drops below your threshold. Keep a scarf over your mouth and nose to warm inhaled air.
• Showers: Lukewarm to warm; avoid sudden temperature shifts from hot to very cold.
• Gym recovery: Skip ice baths; consider contrast therapy only under clinician guidance—and never finish with a very cold plunge. ^[3]
• Diet: Let freezer-cold foods and beverages warm a bit; use straws cautiously if lip or oral hives are common. ^[1]
• Medications: Take daily second-generation H1 antihistamines as prescribed; some patients benefit from dosing before predictable exposures (a winter hike, a cold rink). Treatment plans should follow guideline-based step-up strategies.^{[12] [14]}

The exact trigger mechanism remains under study. Cold appears to change the physical environment of skin mast cells, leading to histamine and mediator release. In many people it is idiopathic (no clear cause), while a minority have secondary cold urticaria associated with conditions such as cryoglobulinemia, chronic lymphocytic leukemia, hepatitis, infectious mononucleosis, and others—one reason clinicians sometimes order screening labs when the history is unusual or severe. ^{[1] [5]}

Cold urticaria can persist for years. In long-term follow-up, roughly one quarter to one third of patients become symptom-free within about 5–10 years; others manage it long-term with trigger control and treatment. ^[1]

See an allergist or dermatologist if you have:

• Hives or swelling reliably triggered by cold
• A history of systemic symptoms (wheeze, faintness) after cold exposure
• Occupational exposures (cold storage, ice rinks) or sports plans (open-water swimming, cold plunges) that make avoidance hard

Ask about:

• Confirmatory testing (ice test and, if available, critical temperature threshold measurement with devices like TempTest)
• A personalized action plan: when to use an antihistamine, when to administer epinephrine, and which activities are safe with precautions
• Step-up therapies if standard antihistamines are insufficient, including immunoglobulin E–targeted biologics or cyclosporine according to guideline pathways ^{[12] [15] [16]}

Can cold urticaria cause anaphylaxis while swimming?

Yes—swimming is the top reported trigger for severe reactions in children and teens, and adults are not exempt. Never swim alone; consider a wetsuit and supervised, gradual entry. ^{[2] [3]}

Is the “ice cube test” safe to try at home?

It is a standard diagnostic tool, but a clinician-supervised test is safest, especially if you have ever felt faint, wheezy, or had mouth or throat symptoms with cold. ^{[1] [6]}

What is the best antihistamine for cold urticaria?

Modern second-generation H1 antihistamines are first-line; if one does not work at standard dose, your clinician may increase the dose up to fourfold or switch to another second-generation option before considering advanced therapies. ^{[12] [13]}

Does cold urticaria ever go away?

It can. A meaningful subset of patients remit within 5–10 years. ^[1]

Should I carry epinephrine?

Discuss with your allergist. Because severe reactions are not rare, many patients—especially those with systemic symptoms or swimmers—are advised to carry an epinephrine autoinjector and know how to use it. 

Cold urticaria is more than “a few hives in winter.” It is a predictable, testable condition with real but manageable risk, especially around cold-water activities and whole-body cold exposure. With evidence-based treatment and smart, often overlooked safety rules, most people can live fully without giving up the activities they love.

Content is educational and not a substitute for personalized medical care. If you suspect cold urticaria—or have ever felt faint, wheezy, or unwell after cold exposure—seek care with an allergy or dermatology specialist.