Cold Panniculitis 

Updated: Apr 28, 2020
Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD 

Overview

Background

Cold panniculitis (CP) is an acute, nodular, erythematous eruption usually limited to areas exposed to the cold. Cold panniculitis results from a cold injury to adipose tissue. 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 to inflammation of the subcutaneous adipose tissue and is particularly likely to occur in patients with chilblains or in paralyzed limbs affected by poliomyelitis. The association with chilblains (perniosis) complicates the terminology and classification of patients with cold injury.[3]

Localized chilling of the tissues of the thigh, buttocks, and lower abdomen is more likely to occur in women who are obese during the winter months because of increased cold exposure. In infants, the cheeks and forehead are areas that may be affected.

Cold panniculitis needs to be distinguished from other disorders such as adiponecrosis subcutanea (subcutaneous fat necrosis of the newborn, cold panniculitis of the newborn) and sclerema neonatorum.[4] Some overlap occurs, and cold panniculitis of the newborn has been associated with ice pack application.[5]

In cold panniculitis of the newborn (adiponecrosis subcutanea), cold injury in the full-term newborn may occur with focal fat necrosis and a granulomatous and fibrous panniculitis in which the infiltrate usually contains multifocal histiocyte foreign body giant cells containing bifringent star-shaped crystals.[6]

In sclerema neonatorum, a usually fatal disorder of infants who are premature or debilitated, histologic findings reveal needle-shaped crystals forming apparent star-shapes in adipose cells. Granulomas are absent. 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. The abnormality probably lies in the chemical composition of the fat tissue. Anoxia, cold, and humidity may play a role. 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. Other cold injuries are relatively frequent.

International

Cold panniculitis is a rare disorder in which the diagnosis probably is hampered by overlapping terminology.

Race

No racial predilection is known.

Sex

Adult women who are obese most commonly have cold panniculitis. During childhood and infancy, an equal incidence exists for the sexes.

Age

Cold panniculitis occurs during infancy and childhood and in adult women who are obese.

Prognosis

The prognosis is excellent because most cases resolve without adverse affects.

Patient Education

Educate patients about avoiding exposure to cold.

 

Presentation

History

The eruptive phase usually begins 48 hours (range, 6-72 h) after a cold injury to exposed or poorly protected areas. The patient may have a history of a febrile illness or other illness without dermatologic findings. It may occur after ice therapy, a first-line treatment for supraventricular tachycardia in neonates.[9]  Equestrian cold panniculitis was documented in a cold-storage-room worker.[10]

Physical Examination

Pertinent physical findings are limited to the skin. Lesions present as localized indurated nodules with ill-defined margins similar to erythema nodosum. Nodules are raised slightly above the skin line. Nodules are firm or hard and cold and painful.[3]

Cutaneous distribution in children characteristically is on the face (cheeks and forehead),[11] as shown in the image below. Skin color changes are red or violet. One report describes toe involvement.[12]

Classic presentation of cold panniculitis with nod Classic presentation of cold panniculitis with nodular red swellings over the cheeks.

In women who are obese, cutaneous distribution characteristically is on the buttocks, thighs, arms, and under the chin (areas poorly protected from the cold). Thigh lesions, in particular, overlap with perniosis.

Complications

Cold panniculitis (CP) is a self-limiting disorder.

 

DDx

Diagnostic Considerations

See the list below:

  • Cold panniculitis neonatorum synonymous with adiponecrosis subcutanea

  • Sclerema neonatorum synonymous with sclerema adiposum neonatorum

  • Chilblain

  • Lupus erythematosus panniculitis[13]

  • Lymphoma cutis[14]

  • Neutrophilic panniculitis[15]

Differential diagnosis also includes poststeroid panniculitis and frostbite.[16]

Cytophagic histiocytic panniculitis often presents with multiple subcutaneous nodules and eventuates in a bleeding diathesis.[17]

In endemic areas, cutaneous leishmaniasis may occasionally be part of the differential diagnosis.[18]

Equestrian perniosis is a rare disorder that appears as tender burning nodular plaques on bilateral thighs after riding in the cold; it tends to promptly resolve and has no known significant systemic disease associations.[19] It is histologically characterized by perivascular lymphocytic infiltrate that prominently involves the fat. Equestrian chilblain is also known as equestrian cold panniculitis.[20]

Familial chilblain lupus may be due to a novel mutation in the exonuclease III domain of 3' repair exonuclease 1 (TREX1).[21, 22]

Subcutaneous panniculitis‒like T-cell lymphoma is also in the differential diagnosis.[23, 24]

Differential Diagnoses

 

Workup

Laboratory Studies

For cold panniculitis (CP), a clinical diagnosis often can be made.

Procedures

Biopsy is reserved for diagnostic problem cases. Punch biopsies usually are inadequate. Deep skin incisional biopsies are required to adequately sample the subcutaneous tissue. Findings are localized to the subcutaneous tissue.

Histologic Findings

The classic features of cold panniculitis on histopathology predominantly are a lobular panniculitis with scattered lymphohistiocytic and eosinophilic infiltrates. The deposition of mucin is a special finding.

 

Treatment

Medical Care

In most instances, cold panniculitis (CP) is a self-limiting disorder and requires only symptomatic relief. Many patients recover if slow rewarming is achieved. Topical therapies are unlikely to penetrate sufficiently to be effective, and systemic agents are required.[25]