How a chilly day can lead to a case of hives

The Cold Case Files

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Pam Pezzin of Freeport was walking in the woods on a winter day back around 1989 when she broke out in hives all over her body, including her stomach, arms, legs and face.

Over the years, she continued to break out in bumps when it was cold outside, and she suffered from symptoms of asthma, too.

She had a period of remission, but the reactions resumed about 10 years ago. "It got severe again," she said.

But none of the doctors could figure out exactly what was wrong with her until she saw allergy, asthma and immunology expert Deborah Gentile in 2009.

Dr. Gentile, director of research, Division of Allergy, Asthma and Immunology at Allegheny General Hospital, told Ms. Pezzin, now 40, she has cold-induced urticaria, urticaria being medical-speak for hives. Cells in her skin were releasing chemicals that cause itching, swelling and redness.

Winter takes toll on the skin

Even for people who don't have cold-induced urticaria, winter can be hard on the skin, says state-licensed clinical esthetician Jennifer Derry, who works in the Shadyside office of plastic surgeon Leo McCafferty.

Multiple layers of clothing and the heat from furnaces and hot showers and baths pull the moisture out of our skin and cause dehydration. "As a result," Ms. Derry said, "we see increasing cases of dry, itching or flaking skin."

Moisturizers help the problem, but some people may need a combination of lotions and treatments to combat winter-beaten skin.

"Humidifiers, fish oil, enzyme facials and hyaluronic acid serums are among the many options for patients," Ms. Derry said. "Hyaluronic acid is naturally found in the body, helping to moisturize from the inside out. By applying more HA to the skin, it helps to hold in more moisture."

Her allergic response to cold -- even autumn's cooler temperatures can prompt her to get hives -- is so severe that sometimes her lips swell, her airways constrict, and she has trouble breathing. "I've been to the emergency room on multiple occasions," said Ms. Pezzin, a social worker. "They did administer epinephrine and breathing treatments, always breathing treatments, because I'm virtually closing up."

Cold-induced urticaria is one of several categories of allergic reactions called physical urticarias.

"It's an interesting phenomenon. There's a whole group of environmental factors that can cause urticaria," Dr. Gentile said.

"It's a medical condition in which the patient breaks out in hives, which are induced usually by various physical or environmental stimuli such as heat, cold, pressure applied to the skin, water, vibration, sunlight, exercise," said Andrej Petrov, medical director of allergy and clinical immunology in a division of pulmonary allergy and critical care medicine at UPMC. "These are all various, but usually there's a trigger that is usually readily identifiable."

For example, Janet Zahorsky of Ambridge another one of Dr. Gentile's patients, has cholinergic, or heat-induced, urticaria. When she is exposed to heat, the 22-year-old College of Wooster junior gets hives, and the reaction is exacerbated by food allergies. If she is exposed to certain foods and goes out in the heat, her hives are worse than if they were just heat-induced.

In some patients who get hives, it is difficult for the allergist/immunologist to identify the trigger. "But with physical urticaria most of the time you can sort of identify the trigger by doing a history from a patient," Dr. Petrov said. "Usually patients will let you know. ... They'll say, 'In cold weather I break out in hives. When I'm running and sweating I break out in hives. I carry a bag and where I put pressure I break out in hives,' so usually patients will have a clue."

If taking a history doesn't work, sometimes the doctors can provoke the allergic response. For example, to test for cold urticaria, they'll put an ice cube in a plastic bag and press it to bare skin for five minutes. "Ten minutes later, they'll break out in a huge hive," Dr. Petrov said.

The trigger for this kind of allergy -- cold, heat, skin pressure, etc. -- causes mast cells, or cells in connective tissue, to burst and release irritating chemicals like histamine into the affected area, causing itching, swelling and fluid leaking from cells.

Cold urticaria is divided into three subtypes and can be very dangerous.

"Most common is primary, or essential, cold urticaria, and the hive is usually localized to the area of exposure," said AGH dermatologist Diane Inserra. Patients usually get it in early childhood and can have it for many years. "It can be very severe, and if somebody were just to jump into ice-cold water and weren't treated, [they can] have cardiovascular collapse and die."

Treatment is usually a combination of antihistamines, although occasionally, Dr. Inserra said, doctors have tried using desensitization, slowly exposing the patient to cold over increasing parts of his or her body.

In secondary cold urticaria, there usually is an underlying disease, like multiple myeloma, hepatitis or mononucleosis for example. Patients "don't just get hives but systemic reactions like headaches and very low blood pressure," she said, "and they can pass out when they're exposed." Antihistamines generally don't help much; instead the allergist works with the patient's personal care physician to diagnose and treat the underlying disease.

The third subtype of cold urticaria is familial or inherited urticaria. "In this the hives definitely burn more than itch," Dr. Inserra said. They also last for about 48 hours, as compared to the 24 usual hours of regular hives. The treatment is anabolic steroids because antihistamines "don't work at all."

There are subtypes for some of the other physical urticaria, too, but "they're a little less complicated than cold urticarias," Dr. Inserra said. The exception is heat urticaria, which, she said, can be very complicated to treat.

In most cases of cold urticaria, over-the-counter antihistamines do the trick. "Most do very well. If [one antihistamine] doesn't work, we switch to another or change the dose," Dr. Gentile said.

For example, Jana Stachowicz, 27, of Shadyside, a dental hygienist who sees Dr. Petrov for cold-induced urticaria, takes 180 milligrams of Allegra twice a day and dresses in layers in the cold. "It keeps [the hives] to a minimum," she said.

But over-the-counter antihistamines didn't work for Ms. Pezzin.

"I was taking copious amounts of Benadryl and rescue inhalers, bronchial dilators," she said. "I was taking Benadryl like you couldn't believe daily. I was really debilitated from this condition. Even a stroll to the mailbox would provoke it -- that's how sensitive it was."

Finally, Dr. Gentile put her back on Xolair, an injectible for allergic asthma Ms. Pezzin receives from her doctor every other week. She had tried it before she was diagnosed with cold-induced urticaria, but the pulmonologist treating her didn't think it was helping and stopped it. Her symptoms worsened. That's when she went to see Dr. Gentile. "The drug was a miracle drug for me," Ms. Pezzin said.

Dr. Petrov had a patient with cold-induced urticaria who had to move to a warmer climate, but that, too, is an extreme case.

Ms. Zahorsky controls her heat-induced urticaria by managing her intake of the foods to which she's allergic. "I eat pretty much everything but rotate how much I have," she said.

"It's triggered by the foods and if I don't eat them, I don't have the reaction. If I do eat the foods and have a reaction, I take Alavert," another over-the-counter antihistamine.

Pohla Smith: or 412-263-1228. First Published February 6, 2012 5:00 AM


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