Summary

Acquired cold-induced urticaria is an uncommon form of chronic urticaria, characterized by development of wheals, angioedema or both in response to cold exposure. In this report it is presented a case of atypical cold urticaria with an unusual phenotype: A female patient covering herself with hijab referred to dermatology outpatient clinic with redness and itching only on the exposed regions. In clinical examination there was eryhthema, strictly delineated by the bounderies of her garment, on her face and hands. She was 34 years old and these manifestations were recurring for three years in winter times with an increasing severity. Total IgE level was 157 IU/mL (normal value < 100 IU/mL). The ice cube test for verification revealed a negative result, which renders the case as atypical according to classification criteria. During one month follow-up with a triple dose antihistamine daily, the attacks were controlled to a great extent. This case, although it was in type-1 severity clinically, the needed antihistamine dose to suppress the manifestations was in the range of type-3 severity. The tendency to increase in clinical manifestations during the course of the disease and the relative higher doses needed to suppress the symptoms should alert the physcian for a probable generalized reaction. Our case, besides being an atypical one, is also interesting to show how the cold sensitivity of the skin can be so precise, displaying such sharp borders.