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Skin, urticaria & angioedema

Inducible urticaria

When cold, heat, pressure, friction or exercise trigger wheals

Download the patient sheet (PDF in French)

In this sheet

Download the patient sheet (PDF in French)

3 essential points

A reproducible trigger is the key
Cold, friction, pressure, increased body temperature, heat or sunlight may trigger different forms of inducible urticaria.
It is generally not an ‘allergy to cold’ or ‘allergy to sport’
The stimulus triggers mast-cell activation. Several subtypes may coexist, and chronic spontaneous urticaria may also be present.
Some situations require particular precautions
Cold urticaria can exceptionally cause a generalised reaction, especially with extensive cold-water immersion. Risk must be assessed individually.

The main forms

Type: Symptomatic dermographism
Example trigger: Friction, scratching or light pressure on the skin.

Type: Cold urticaria
Example trigger: Cold air, water, objects or food depending on the individual.

Type: Cholinergic urticaria
Example trigger: Exercise, a hot shower, ambient heat or emotion: increased body temperature.

Type: Delayed pressure urticaria
Example trigger: Prolonged pressure: bags, belts, standing or manual work.

Type: Other rarer forms
Example trigger: Local heat, sunlight, water or vibration.

Type	Example trigger
Symptomatic dermographism	Friction, scratching or light pressure on the skin.
Cold urticaria	Cold air, water, objects or food depending on the individual.
Cholinergic urticaria	Exercise, a hot shower, ambient heat or emotion: increased body temperature.
Delayed pressure urticaria	Prolonged pressure: bags, belts, standing or manual work.
Other rarer forms	Local heat, sunlight, water or vibration.

Understanding triggers

Symptomatic dermographism: ‘my skin writes’

After rubbing or scratching, an itchy raised line may appear over the stimulated area. Temporary redness after friction alone is not enough to diagnose symptomatic dermographism: the lesions must be genuinely urticarial and troublesome.

Cold urticaria: the main safety issue

Reactions may remain local, but extensive cold exposure can cause a much more widespread reaction. Swimming or immersion in cold water is particularly important to discuss with your doctor.

Known cold urticaria: take care with immersion

Do not test your tolerance by suddenly entering cold water. If cold has already caused faintness, breathing difficulty or a generalised reaction, you need a personalised safety plan.

Not everyone with cold urticaria automatically needs an adrenaline auto-injector. The decision depends on previous reactions, predictable exposure and risk level.

‘Can I do an ice-cube test at home?’

No. Challenge tests confirm the diagnosis and may measure a trigger threshold. They must be adapted to the subtype and risk. A significant reaction must never be deliberately provoked at home.

Cholinergic urticaria: exercise, heat and hot showers

It typically causes many small, very itchy papules when body temperature rises, for example during exercise, a hot shower, high heat or emotion. The mechanism is not simply a ‘sweat allergy’.

Delayed pressure urticaria

Lesions may appear several hours after prolonged pressure, making the link less obvious. Examples include bag straps, belts, palms after manual work and soles after prolonged standing. Areas may be swollen, tender or painful as well as itchy.

Must the trigger be avoided completely?

Not automatically. The aim is to identify problematic situations and reduce major exposures without unnecessarily stopping useful or enjoyable activities. Two people with the same form may have very different thresholds.

How is the diagnosis made?

The clinical history should describe the stimulus, delay, appearance and duration of lesions and whether the reaction was local or generalised. Depending on the subtype, a specific and preferably standardised challenge test may be offered: friction or dermographism, cold, exercise or increased body temperature, pressure, or another stimulus suggested by the history.

The aim is not to ‘cause the biggest possible reaction’, but to confirm the mechanism under controlled conditions and sometimes estimate the threshold.

Is it a food allergy?

Generally not. Urticaria reproducibly triggered by cold, pressure or increased body temperature is not usually explained by food. A reaction that occurs only when certain foods are combined with exercise belongs to a different condition.

Treatment: a stepwise strategy

Step: 1. First line
Principle: A second-generation H1 antihistamine according to the medical plan.

Step: 2. Inadequate control
Principle: The doctor may adjust the dose or strategy; do not change treatment yourself.

Step: 3. Difficult forms
Principle: Specialist care and, in some situations, a biologic may be discussed.

Step	Principle
1. First line	A second-generation H1 antihistamine according to the medical plan.
2. Inadequate control	The doctor may adjust the dose or strategy; do not change treatment yourself.
3. Difficult forms	Specialist care and, in some situations, a biologic may be discussed.

For several forms of inducible urticaria, treatment evidence is less robust than for CSU and some uses are off-label. Treatment must therefore be individualised.

Can several forms occur together?

Yes. Several inducible urticarias may coexist, and chronic spontaneous urticaria may also be present. Having some wheals ‘for no reason’ and others after a reproducible trigger does not invalidate the diagnosis.

See ‘Chronic spontaneous urticaria’.

Preparing for the consultation: five useful details

the exact trigger;
the delay between the stimulus and the wheals;
a photograph of the lesions if possible;
their duration;
whether the reaction was local only or included systemic symptoms.

For cold, specify cold air, water, an object, cold food or drink, or swimming. For cholinergic urticaria, specify exercise, a hot shower, heat or emotion.

Describe your skin symptoms

Common misconceptions

Misconception: ‘I am allergic to cold.’
SOS Allergo guidance: The expression is common, but this is usually inducible urticaria rather than a classic allergy to an allergen.

Misconception: ‘Urticaria during sport means I must stop sport.’
SOS Allergo guidance: Not automatically: the mechanism must be clarified and exercise-induced anaphylaxis excluded.

Misconception: ‘I can do a large ice-cube test at home.’
SOS Allergo guidance: No. Tests must be adapted to risk.

Misconception: ‘Several triggers mean the diagnosis is wrong.’
SOS Allergo guidance: No. Several forms may coexist.

Misconception: ‘Cold only causes local wheals.’
SOS Allergo guidance: False. Extensive exposure can sometimes cause a systemic reaction.

Misconception: ‘My antihistamine protects me whatever happens.’
SOS Allergo guidance: No, especially with exposure already identified as potentially dangerous.

Misconception	SOS Allergo guidance
‘I am allergic to cold.’	The expression is common, but this is usually inducible urticaria rather than a classic allergy to an allergen.
‘Urticaria during sport means I must stop sport.’	Not automatically: the mechanism must be clarified and exercise-induced anaphylaxis excluded.
‘I can do a large ice-cube test at home.’	No. Tests must be adapted to risk.
‘Several triggers mean the diagnosis is wrong.’	No. Several forms may coexist.
‘Cold only causes local wheals.’	False. Extensive exposure can sometimes cause a systemic reaction.
‘My antihistamine protects me whatever happens.’	No, especially with exposure already identified as potentially dangerous.

Key points

Inducible urticaria appears after a specific, reproducible stimulus.
Cold urticaria, dermographism, pressure urticaria and cholinergic urticaria are among the most common forms.
Cold urticaria requires particular care with swimming and immersion.
Challenge tests are performed under controlled conditions; do not try to provoke a significant reaction at home.
Treatment and precautions must be adapted to your subtype and level of risk.

Chronic spontaneous urticaria Adrenaline auto-injector Preparing for allergy tests

Main references

Zuberbier T, et al. The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for urticaria. Allergy. 2022;77:734-766. DOI: 10.1111/all.15090. PMID: 34536239.
Maurer M, Bonnekoh H, Grekowitz E, et al. An algorithm for the diagnosis and treatment of chronic inducible urticaria, 2024 update. Allergy. 2024;79(9):2573-2576. DOI: 10.1111/all.16250. PMID: 39056446.
Ritzel C, Altrichter S. Chronic Inducible Urticaria. Immunol Allergy Clin North Am. 2024. DOI: 10.1016/j.iac.2024.03.003. PMID: 38937008.
Lee R, Bernstein JA. Chronic spontaneous urticaria and chronic inducible urticaria. J Allergy Clin Immunol. 2025;156(3):546-556. DOI: 10.1016/j.jaci.2025.05.019. PMID: 40451490.
Bizjak-Suran M, Fležar M, Pereira MP. Pathophysiology and emerging treatments for dermographic, cholinergic and cold urticaria. J Eur Acad Dermatol Venereol. 2026. DOI: 10.1111/jdv.70559. PMID: 42299718.
Ahsan DM, et al. Subtypes of Atypical Cold Urticaria and Recommendations for Their Diagnostic Workup. J Allergy Clin Immunol Pract. 2025;13(9):2370-2380.e2. DOI: 10.1016/j.jaip.2025.07.019. PMID: 40706706.

General information: this sheet does not make a diagnosis and does not replace a consultation, supervised challenge test or personalised emergency plan. For a severe reaction with breathing difficulty, faintness or rapid worsening, call 15 or 112.

Scientific review: September 2026 · sosallergo.fr

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