Prevalence, Management, and Anaphylaxis Risk of Cold Urticaria: A Systematic Review and Meta-Analysis

Background Cold urticaria is a subtype of chronic inducible urticaria (CIndU) associated with significant morbidity and a risk of anaphylaxis. Few studies have assessed the prevalence, management, and prevalence of associated anaphylaxis of cold urticaria. Objectives To evaluate the prevalence of cold urticaria among CIndU and chronic urticaria (CU) cases, to assess the management of cold urticaria and to determine the prevalence of associated anaphylaxis. Methods PubMed and EMBASE were searched for studies pertaining to cold urticaria and/or CIndU published in the last 10 years. Meta-analyses were conducted to evaluate: the prevalence of cold urticaria among CIndU and chronic urticaria (CU) cases, the management of cold urticaria with H1-antihistamines and omalizumab and the prevalence of associated anaphylaxis. Results Twenty-two studies were included in the systematic review and 14 in the meta-analysis. The pooled prevalence of cold urticaria among CU and CIndU cases were 7.62% (95%CI: 3.45%, 15.99%; I2=98%) and 26.10% (95%CI: 14.17%, 43.05%; I2= 97%), respectively. Cold urticaria was managed by H1-antihistamines in 95.67% (95%CI: 92.47%, 97.54%; I2=38%) of patients and omalizumab in 5.95% (95%CI: 2.55%, 13.27%; I2=83%) of patients. The pooled prevalence of anaphylaxis among cold urticaria cases was 21.49% (95%CI: 15.79%, 28.54%; I2=69%). Conclusion Cold urticaria constitutes an appreciable proportion of CIndU and CU cases and is predominantly managed with H1-antihistamines, with a minority of patients receiving omalizumab. Anaphylaxis is not rare, and epinephrine auto-injector (EAI) prescription may be considered.