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Q. I experience hives whenever I go outside in freezing weather or dip into cold water. What can I do?

A. You likely have what’s called cold urticaria, in which the stimulus of cold releases histamine into the body and causes hives and swelling. Cold urticaria symptoms occur soon after the skin is exposed to cold temperatures or cold water.

The condition is mostly not serious but severe reactions, or anaphylaxis, do occur – typically when the whole body is impacted by cold, such as when swimming in cold water. This can cause a drop in blood pressure, fainting and even death. Swelling of the tongue or throat can lead to difficulty breathing.

To prevent symptoms, it’s obviously important to avoid cold temperatures and cold water. If you live in a cold weather area of the country, stay indoors as much as you can when temperatures dip. Don’t go swimming in cold water. Avoid the freezer section at the grocery store if you have severe symptoms.

There’s no set temperature that can cause symptoms. Patients with cold urticaria have different thresholds. For some it has to be below freezing, but for others it’s cool weather. If symptoms are severe or impacting your quality of life, or if you experience other non-skin symptoms along with cold urticaria, then it’s time to consider seeing a specialist such as a board-certified allergist.

For most patients, antihistamines should clear up hives. Antihistamines can also be helpful with managing the condition; when patients know they will be exposed to cold, taking an antihistamine can help the body better tolerate it.

Cold urticaria patients typically won’t need an epinephrine auto-injector unless they are at risk for a severe reaction, or anaphylaxis. Epinephrine is the only medication proven to stop anaphylaxis.

An allergist in a location where it doesn’t get extremely cold will likely only prescribe an epinephrine auto-injector if it’s requested, or if the patient is worried his or her airways could swell as a result of a reaction. Allergists in colder parts of the country may have a different approach.

Allergists test for cold urticaria by taking an ice cube, wrapping it up in plastic, and placing it on the skin for a short period of time. If it’s cold urticaria, a hive will pop up.

Some rare diseases are associated with cold urticaria. Talk with your allergist if your symptoms are accompanied by joint pain or fever following exposure to cold. It’s important to provide a detailed history of your symptoms, including family history, to the allergist for a complete diagnosis.

Q. I have red itchy bumps on my arms that look like mosquito bites (but are not), and they leave marks. Could this be an allergic reaction to something?

A. Based on your description of symptoms, you could be experiencing an allergic reaction to something in your environment; such as something you are eating, something touching your skin or something you are inhaling from the air. You should discuss your symptoms, and potential strategies for diagnosing and managing them, with your allergist.

Q. I have hives, and have been to an allergist, but haven't been able to determine a cause. I have Hepatitis B - could my hives be related to that?

A. Unfortunately, many patients who struggle with urticaria (or hives) are unable to discover a cause.

Urticaria has been reported in association with a wide variety of viral illnesses.  It is certainly possible that your urticaria could be related to Hepatitis B infection. It is also possible that your urticaria is not related to Hepatitis B infection.

Acute urticaria has been observed in the early stages of Hepatitis A, B, and C infection.  There is a 2012 case report published in the medical literature of a patient with chronic urticaria following an acute infection with Hepatitis A.  

Your allergist can help with personalized recommendations and strategies for your evaluation and treatment.

Q. I had a serious allergic reaction to mango, and the skin on my face is red, itching, and pimply. I was given medication to relieve the allergy, and have been taking it for two days, but my skin is still red, dry, and burning. Can I apply lotion or cream to help calm my skin?

A. Allergic contact dermatitis to mango is a serious problem for some people.  The skin of mangoes contains a chemical called urushiol, which is actually the same allergen found in poison ivy and similar plants (poison oak, poison sumac).  Unfortunately, once the reaction has progressed to the point of causing blisters, topical medications are not always helpful.  Oatmeal baths and using a cool, wet compress may help to soothe your skin. 

If the rash continues, you should see your allergist, as it is possible to develop a secondary skin infection due to the irritation and skin breakdown from the allergic reaction.  

Q. I have a reaction to sunscreen. I can put it on indoors and I'm fine. But the moment I step outside for 30 minutes or more, I get red and swollen, and then itchy bumps form. This lasts for several days after use, so now I don’t use any sunscreen. I've tried most of the sensitive brands, too. Am I just out of luck?

A. It sounds as if you are experiencing a photo-allergic reaction or photocontact dermatitis, meaning that the sunscreen product in combination with UVA/B rays causes you develop an allergic reaction.  Oxybenzone (benzophenone-3), the most widely used UVA blocking agent, is the most common cause of sunscreen-induced photo-allergic contact dermatitis. Other sunscreen agents known to induce photo-allergic reactions are the benzophenones, cinnamates, and dibenzoylmethanes.

Titanium dioxide and zinc oxide are inorganic filters which have excellent coverage for UVA1, UVA2 and UVB. I would suggest either one or a combination of these agents, as they will offer broad-spectrum protection with minimal irritation, sensitization, and skin penetration. Look for ones with the fewest added ingredients. Try to avoid fragrances. Although rarely used these days, always avoid PABA-containing products. 

Belly Buttons & Babies Sunscreen Lotion (SPF30) and Honest Mineral Sunscreen Spray (SPF30) both appear to fit the recommended criteria above, though I can’t specifically recommend either, as I have no personal experience with them.

You might also consider clothing products and hats that offer sun protection.

Your allergist can help with personalized recommendations and strategies.

Q. Can hives appear around the ankle or feet area?

A. Yes.  Hives (or urticaria) are itchy pink or pale swellings that appear as welts and can occur on any part of the skin.  Each individual hive typically lasts minutes to hours before fading away without leaving a mark.  New hives can arise as old ones fade away.  They can vary in size from a few millimeters to inches, and can blend together to form larger swellings.

Hives result from blood plasma leaking through small gaps between the cells lining small blood vessels in the skin.  Histamine is a natural chemical released from allergy cells, which lie along the blood vessels in the skin.  Histamine causes the itching, swelling, and red color of hives.

Q. Wherever my skin touches itself, I break out in an itchy red rash. It happens on my underarms, under my breasts, on my legs if I sleep without bottoms, in the crease of my arms if bent together for a while, etc. What is causing this and what should I do to relieve it?

A. These symptoms may be due to a condition known as dermatographism, a form of physically-induced hives. In patients with dermatographism, superficial pressure applied to the skin triggers release of histamine from mast cells in the skin. This condition may affect up to 5% of the general population. Once released, histamine causes immediate itching as well as wheals (localized hives) and redness. Dermatographism tends to be a chronic condition that can last for months or years. In many cases symptoms can be prevented by taking a non-sedating antihistamine on a daily basis.  

Q. I'm 16 years old and live in Branson, Missouri. I seem to get hives around the same time each year, though I haven't changed anything in my life. Last year, it began around the end of August/early September and they were gone by May/June. This year, it has happened again. The hives are around my underwear line, my back, and my sides. The hives are raised and are no bigger than a quarter. As the weather gets colder, they worsen. Why am I getting these hives?

A. From your description of your symptoms, it sounds like you may be struggling with cold urticaria. In patients with cold urticaria, hives develop after being exposed to cold temperatures, and contact with cold objects.  Cold urticaria can be a primary condition or related to an underlying medical condition. Some patients with cold urticaria have a family history of cold urticaria.  

Unfortunately, for many cases of cold urticaria, a cause cannot be determined.

Your allergist will likely do some testing, to include possibly placing a cold object on a portion of your skin.  Additional studies may be indicated, based on your personal and family history.

Avoidance of cold exposures and non-sedating anti-H1 antihistamines are generally the first treatments for cold urticaria. If these strategies are ineffective, higher antihistamine dosages may be tried, or other agents may be attempted.  You should discuss your symptoms, an evaluation tailored to you, and potential strategies for managing symptoms with your allergist.