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In most cases, cold urticaria is diagnosed through patient history. However, an ice cube test can be performed on the forearm, and here is the result after 5 minutes:
Ice cube test
The latest national recommendations on urticaria (2023) suggest performing a complete blood count and measuring C-Reactive Protein (CRP) to rule out differential diagnoses.
Other tests will be requested only if there are specific indications (such as searching for cryoglobulins and cold agglutinins).
You diagnose typical cold urticaria.
What treatments can you offer?
The patient describes almost daily outbreaks, especially in winter, which significantly impact his quality of life.
As a first option, you can offer a treatment with second-generation anti-H1 antihistamines at the conventional dosage of 1 tablet/day for adults (single dose, according to marketing authorization), an effective and well-tolerated treatment.
If symptoms are insufficiently controlled, you may propose increasing the dosage up to four times the recommended dose. The anti-H1 antihistamines studied at quadruple doses for cold urticaria include: Bilastine, Desloratadine, Rupatadine.
What treatment can you offer after 3 months?
You see the patient again 3 months later. He reports only modest efficacy of anti-H1 antihistamines at 4 tablets/day, with almost daily outbreaks persisting.
Given the daily discomfort and significant impact on quality of life, you could consider starting treatment with OMALIZUMAB 150 mg per month (dosage based on literature, off-label use), combined with anti-H1 antihistamines, which should continue at quadruple dosage.
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