Cold panniculitis (CP) is a disorder that can affect both adults and children. It is caused by exposure of various regions of the body to a cold temperature and, subsequently, there is a wide range of areas on which it may appear.

Patients may present with indurated nodules in areas of the body exposed to cold. The nodules have ill-defined margins and appear approximately 1 to 3 days following the exposure. The erythematous lesions are expected to develop to painful and firm nodules over the days [1]. Pediatric patients tend to exhibit them on the forehead and cheeks and rarely on the extremities such as the toes, with the lesions assuming a lilac/red color [2] [3] [4]. This is attributed to these two areas of the body being more constantly exposed to a cold temperature during the winter and less protected [5]. Cold panniculitis does not lead to systemic involvement and, therefore, constitutional symptoms are not reported. Except for the characteristic dermatological manifestations, a medical history of fever is the sole complaint that may accompany a case of CP.

The induration gradually subsides and the disorder is a self-limiting one, eventually resolving in approximately two weeks [6]. Ulceration of the nodules or plaque formation and crusting thereof may also be observed [5].

Several sub-categories of CP have been reported in the literature. Equestrian cold panniculitis is a type of CP that involves nodular lesions appearing in young women who engage in horse-riding [7]. Cold is also the culprit behind these cases and the lesions are typically observed on the upper lateral part of the thigh, with bilateral involvement being a possibility. Popsicle panniculitis is a type of cold panniculitis that occurs following sucking on an ice cube or popsicle, with lesions appearing on the cheeks. Lastly, a case has been reported, concerning CP-induced by a cold therapy unit, in which the rash failed to appear until 10 days after treatment was started [8].

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• Back Pain

  We describe 2 adult patients using ice-pack therapy for chronic back pain who developed erythematous, purpuric plaques at the site of ice-pack application. [ncbi.nlm.nih.gov]

A targeted medical history and careful physical examination are the key steps towards achieving an accurate diagnosis, given that CP is primarily seen clinically.

There are usually no laboratory tests that can aid in the diagnosis of this medical entity, as cryofibrinogens and cryoglobulins tend to be negative [7]; a histopathological analysis of a biopsy sample harvested from a lesion is the sole means of confirmation of CP. A biopsy is usually ordered in diagnostically challenging cases of cold panniculitis. The following results are compatible with the disorder:

• Infiltration of fat lobules by lymphocytes and histiocytes. The perivascular infiltration in the dermis by lymphocytes is observed predominantly at the dermal-epidermal junction.
• The absence of vasculitis.
• Abnormal findings are only exhibited in the adipose tissue.

To our knowledge, this is the first report of cold panniculitis caused by treatment of a cardiac arrhythmia with ice packs. [ncbi.nlm.nih.gov]

Panniculitis Treatment The treatment of Panniculitis is usually carried out in different ways. If the doctor diagnoses you with Panniculitis, he would usually prescribe you anti-inflammatory medicines of a non-steroidal nature. [primehealthchannel.com]

Prior to treatment. (Photograph courtesy of Christopher Zachary, FRCP) Figure 2. 3 months post-treatment. [dermquest.com]

Our staff has completed hundreds of treatments and has received the highest level of CoolSculpting™ training possible. [seattleaesthetics.com]

Prognosis The prognosis is excellent because most cases resolve without adverse affects. Patient Education Educate patients about avoiding exposure to cold. [emedicine.medscape.com]

The prognosis is also poorer in sclerema neonatorum in contrast to SCFN. Cold panniculitis is limited to areas exposed to cold and was ruled out due to absence of history of exposure to cold. [e-ijd.org]

However, the disease can be limited to skin with a long clinical course of multiple recurrences and have a good prognosis. [44], [45], [46], [47], [48] Microscopically, the characteristic lesions show panarteritis involving the medium- to small-sized [ijdpdd.com]

Etiology Different predisposing factors play an important role in the etiology of subcutaneous fat necrosis of the newborn. [drmhijazy.com]

In most cases, the etiologic factor is chemical, by the subcutaneous self-injection of disparate substances, usually denied by patients, being a manifestation of an underlying psychiatric disturbance, or of drug or alcohol abuse. [link.springer.com]

Idiopathic nodular panniculitis, also known as Weber-Christian disease, is of unknown etiology. Lesions most typical on the lower extremities, but can occur on the trunk. There can be an associated fever, malaise, arthralgia, and myalgia. [skincareguide.ca]

These changes also may occur in those infants classified as being sickly in whom minimal exposure to the cold has occurred. [6] Etiology Cold panniculitis is caused by cold injury in children and in women who are obese. [emedicine.medscape.com]

Adult cases were not reported until 1963 by Solomon and Beerman 4 and then in 1980 by Beacham et al. 5 Etiologies for children have included popsicles, ice packs applied to the face to control supraventricular tachycardia or to the lower extremities after [mdedge.com]

It may also be caused by whole-body cryotherapy [7] or ice therapy for supraventricular tachycardia. [8] Epidemiology Frequency United States Frequency peaks during infancy and childhood and in adult women who are obese. [emedicine.medscape.com]

Many patients classified as having cold panniculitis or equestrian cold panniculitis have forms of perniosis that represent dermal vascular injury rather than true panniculitis. [1, 2] Pathophysiology In cold panniculitis, localized cold damage leads [emedicine.medscape.com]

Vasodilator drugs are not effective in preventing or treating cold panniculitis. [dermaamin.com]

Topical therapies are unlikely to penetrate sufficiently to be effective, and systemic agents are required. [22] Author Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine [emedicine.medscape.com]

Treatment of cold panniculitis is based on the prevention of further insult. The panniculitides can be a complex dermatologic entity for both dermatologists and dermatopathologists. [mdedge.com]

1. Ferrara G, Cerroni L. Cold-Associated Perniosis of the Thighs ("Equestrian-Type" Chilblain): A Reappraisal Based on a Clinicopathologic and Immunohistochemical Study of 6 Cases. Am J Dermatopathol. 2016 Oct;38(10):726-31.
2. Huang FW, Berk DR, Bayliss SJ. Popsicle panniculitis in a 5-month-old child on systemic prednisolone therapy. Pediatr Dermatol. 2008 Jul-Aug;25(4):502-3.
3. Holla RG, Prasad AN. Cold panniculitis neonatorum. Indian Pediatr. 2009 Jan;46(1):75.
4. Patterson JW. Panniculitis. In: Bolognia J, Jorizzo J, Rapini R, eds. Dermatology. 2nd ed. St. Louis, MO: Mosby Elsevier;2008:1515-1530.
5. Quesada-Cortés A, Campos-Muñoz L, Díaz-Díaz RM, et al. Cold panniculitis. Dermatol Clin. 2008;26:485-489.
6. Page EH, Shear NH. Temperature-dependent skin disorders. J Am Acad Dermatol. 1988;18(5, pt 1):1003-1019.
7. Beacham BE, Cooper PH, Buchanan CS, Weary PE. Equestrian cold panniculitis in women. Arch Dermatol. 1980 Sep;116(9):1025-7.
8. Lipke MM, Cutlan JE, Smith AC. Cold Panniculitis: Delayed Onset in an Adult. Cutis. 2015 January;95(1):21-24