PECU: A multicenter study on pediatric patients with cold-induced urticaria

Cold-induced urticaria (ColdU) is a rare chronic inducible urticaria that can cause systemic reactions, including cold-induced anaphylaxis (ColdA), but pediatric data are limited. The aim of this study was to evaluate the clinical characteristics, comorbidities, management approaches, risk of anaphylaxis, and long-term course of ColdU in a pediatric cohort, and to identify risk factors for ColdA, determinants of disease resolution, and predictors of persistence into adulthood.

This retrospective multicenter study included 203 pediatric patients with ColdU across 30 centers in Türkiye. Clinical characteristics and management of patients were analyzed. Logistic regression was used to identify factors associated with ColdA and disease resolution.

The median age at diagnosis was 14.3 years, and the median age at onset was 10 years; 56.1% of patients were female. ColdA occurred in 17.2%, with increased risk associated with male sex, autoimmune comorbidities, older age, and triggering by cold food/beverage ingestion. Most patients (82.2%) received second-generation H1-antihistamines; omalizumab achieved >90% symptom control in 12 refractory cases. Over a median 3.5-year follow-up, 30.5% achieved disease resolution (median duration: 18 months). The history of anaphylaxis and comorbid atopy significantly reduced the likelihood of remission. Some patients showed adult persistence, without clear predictors.

ColdA may occur even without classic high-risk features; pediatric ColdU management should be guided by individualized risk assessment, prioritizing clinical risk factors-such as older age, high-risk cold triggers, angioedema, and autoimmune comorbidities-over isolated diagnostic parameters. In refractory cases, omalizumab is an effective and well-tolerated option. Prior anaphylaxis and comorbid allergic disease predicted poorer remission.