Cold urticaria in cold-water and open-water swimmers: anaphylaxis risk, diagnosis and practical recommendations: a narrative review
DOI:
https://doi.org/10.12775/QS.2026.79.76793Keywords
cold urticaria, anaphylaxis, open-water swimming, winter swimming, cold water immersion, epinephrine, athletes, water safetyAbstract
Background. Cold urticaria (ColdU) is a chronic inducible urticaria in which cold activates skin mast cells. Cold-water and open-water swimming are increasingly popular. In people with ColdU, whole-body immersion can provoke life-threatening reactions.
Aim. To review data on the risk of anaphylaxis in swimmers with ColdU, its diagnosis and management, and to propose practical recommendations for cold-water and open-water swimming
Material and methods. Narrative review of guidelines, systematic reviews, randomised trials, cohort studies and case reports identified in PubMed and reference lists.
Results. In most cohorts, anaphylaxis occurred in 17–37% of patients with ColdU. Complete cold-water immersion was its most frequent trigger. In water, early anaphylaxis is easily mistaken for cold shock, and rescue from the water carries additional risk. Standard cold stimulation tests are negative in up to one third of patients. Open-water races may be held in water as cold as 16 °C, which is below the critical temperature threshold of many patients. Intramuscular adrenaline is the treatment of choice, yet autoinjectors are underprescribed. Higher-dose antihistamines and omalizumab improve disease control but have not been shown to prevent anaphylaxis during immersion.
Conclusions. Swimmers with ColdU need individual risk assessment, education, supervised swimming with adrenaline at hand and horizontal extraction from the water. Prospective data from athletes are lacking.
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