Anticipating Iceland: Ice-pack dermatosis

By Warren R. Heymann, MD, FAAD
April 10, 2024
Vol. 6, No. 15

Iceland beckons. Many of our plans were scuttled by COVID-19, including a long-planned tour of Iceland, which (as of this writing) is exactly two months away.* My wife and I eagerly await the other-worldly topography, unpronounceable waterfalls, midnight sun, and the warmth of the Blue Lagoon. The depiction of Iceland as the “land of fire and ice” is apt. As a dermatologist, when I hear that phrase, my mind wanders to erythema ab igne and cold-induced dermatoses. (*The trip exceeded my expectations — the photo is the Godafoss waterfall.)

Cold-induced dermatoses include frostbite, pernio, cold panniculitis, equestrian cold panniculitis (perniosis), subcutaneous fat necrosis of the newborn, ice-pack dermatosis (IPD), cold urticaria, and disorders related to cryoproteins (cryoglobulins, cryofibrinogens, cold agglutinins). (1,2,3) This commentary will focus on IPD.

West et al first described IPD in two adults (a 50+ year-old woman and a 20+ year-old man) using ice-pack therapy for chronic back pain. Each developed erythematous, purpuric plaques where the ice-pack was applied. Biopsies from each patient revealed subtle vacuolar interface changes, a superficial and deep perivascular and periadnexal lymphocytic infiltrate, a lobular lymphocytic panniculitis, small clusters of CD123+ cells, and increased dermal mucin. These changes bear a striking resemblance to cutaneous lupus erythematosus (CLE). The authors noted a spectrum of overlapping histologic features with perniosis and cold panniculitis; the major mimic is CLE, which characteristically displays a more diffuse lobular panniculitis with prominent hyaline necrosis and larger clusters of CD123+ cells. (4)

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The pitfall of dermatopathologists misdiagnosing IPD as CLE was emphasized by Haber et al in the report of a 59-year-old woman with a history of spinal stenosis, lumbar disc herniation, and multiple other disorders, who had painful, reticulated, violaceous patches on her lower back for several years; this was initially interpreted as discoid lupus erythematosus histologically. Only through careful clinical-pathologic correlation was she correctly diagnosed with IPD. (5) Tran et al reported that direct immunofluorescence (DIF) might differentiate IPD (referred to in the article as ice-pack perniosis) from autoimmune perniosis, with DIF either being negative or displaying a nonspecific C3 immunoreactivity in IPD. (6)

In their review of IPD, Sabeti et al note that most reported cases are in patients with chronic low back pain, presenting clinically with painful erythematous purpuric papules and plaques with ulcerations on the lower back and buttocks. (7) Avoidance of ice packs is the cornerstone of therapy — resolution of lesions may occur within weeks, such as in the case of a 51-year-old woman with IPD whose lesions resolved two weeks after discontinuation of ice packs. (1) Topical steroids have been utilized; intralesional triamcinolone may be effective. (7,8) For recalcitrant IPD lesions, oral prednisone and hydroxychloroquine may be considered. (6)

The pathophysiology of IPD is enigmatic. Although the histologic picture mimics lupus, there is no evidence of autoimmunity by routine tests (ANA, cryoproteins, etc.). The predisposition of infants having cold panniculitis due to the elevated freezing point of fat due to a higher saturated-to-unsaturated fat ratio is unlikely to be relevant in adults. Untold millions apply ice packs for pain — the paucity of reports may be due to the rarity of IPD. Alternatively, perhaps it is not rare and astute patients realize that lesions appear where they have applied an ice pack, discontinue it, and the lesions resolve. Regardless, clinicians should recognize IPD and advise patients accordingly. Providing pertinent clinical information to a dermatopathologist may prevent a misdiagnosis of lupus.

Point to Remember: Ice-pack dermatosis (IPD) usually presents on the lower back and buttocks as painful erythematous papules and plaques. IPD may mimic lupus erythematosus histologically, emphasizing the need for careful clinical-pathologic correlation. Avoidance of ice packs is the cornerstone of therapy for this disorder.

Our expert’s viewpoint

Nathan W. Rojek, MD, FAAD
Assistant Professor
Director, Inpatient Dermatology
Associate Director, Dermatology Residency Program
Department of Dermatology
UC Irvine Health

I was born and raised in Buffalo, New York, which is a city known best for its chicken wings (I’ve been a vegetarian for over 10 years now, but I had my fill in my omnivorous younger days), close proximity to Niagara Falls (no offense to Dr. Heymann as the Godafoss waterfall in Iceland looks beautiful, but it does not beat Niagara in my heavily biased opinion), hapless professional sports teams (I am a lifetime member of the Bills Mafia), and blizzards. My idea of fun is leaving the warm, sunny beaches of Orange County to summit snow-capped mountains and hike glaciers in Alaska.* Consequently, I thought I knew something about the cold. But I was frozen in my tracks when a 60-year-old man with chronic back pain presented to me with a 2-year history of a worsening violaceous, slightly atrophic-appearing, indurated plaque.

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My patient reported that, to relieve his back pain, he regularly applied icepacks to the area, but I thought little of it as I was unaware of ice-pack dermatosis as an entity at that time. Punch biopsies demonstrated the characteristic histologic features as described by Dr. Heymann. Given the histologic pattern resembling cutaneous lupus, I screened him for an underlying connective tissue disease: he had a negative review of systems, no personal or family history of autoimmune disorders, and a negative anti-nuclear antibody test. Naturally, then, I did what most confused academic dermatologists do: I presented his case at my department’s grand rounds. I am fortunate to work with brilliant residents and one of them, Dr. Suzanne Ward Birmingham (now a still-brilliant fellow at UCSF), connected the dots and proposed the diagnosis of ice-pack dermatosis after finding some of the other cases referred to by Dr. Heymann. I was convinced cold was the culprit, so he was advised to avoid icepack application and treated with one intralesional injection of triamcinolone 5mg/cc and topical clobetasol ointment twice daily. Significant improvement was noted after 8 weeks so all pharmacotherapy was stopped, and he achieved complete resolution over the next several weeks. Now, years later, he continues to abstain from ice-pack use and he has not had a recurrence.

It chills me to think that my patient could still be dealing with this issue if I had not sought help from others to arrive at the right diagnosis. Dermatology is a humbling profession and, when facing a vexing clinical scenario, it can feel like one is walking alone coldly in the dark, just like on a winter night in Buffalo…or in Iceland, where, coincidentally, I will visit next January with the hope of seeing the Northern Lights for the first time. I applaud Dr. Heymann for shedding light on this esoteric and enigmatic entity to bring some warmth to dermatologists, dermatopathologists, and patients alike.

1. Saenz Ibarra B, Meeker J, Jalali O, Lynch MC. Cold-Induced Dermatoses: Case Report and Review of Literature. Am J Dermatopathol. 2018 Apr;40(4):291-294. doi: 10.1097/DAD.0000000000001018. PMID: 28984694.

2. Ginter K, Ahsan DM, Bizjak M, Krause K, Maurer M, Altrichter S, Terhorst-Molawi D. Cryoglobulins, Cryofibrinogens, and Cold Agglutinins in Cold Urticaria: Literature Review, Retrospective Patient Analysis, and Observational Study in 49 Patients. Front Immunol. 2021 May 25;12:675451. doi: 10.3389/fimmu.2021.675451. PMID: 34113348; PMCID: PMC8186313.

3. Diamantis S, Bastek T, Groben P, Morrell D. Subcutaneous fat necrosis in a newborn following icebag application for treatment of supraventricular tachycardia. J Perinatol. 2006 Aug;26(8):518-20. doi: 10.1038/sj.jp.7211549. PMID: 16871224.

4. West SE, McCalmont TH, North JP. Ice-pack dermatosis: a cold-induced dermatitis with similarities to cold panniculitis and perniosis that histopathologically resembles lupus. JAMA Dermatol. 2013 Nov;149(11):1314-8. doi: 10.1001/jamadermatol.2013.6302. PMID: 24026341.

5. West SE, McCalmont TH, North JP. Ice-pack dermatosis: a cold-induced dermatitis with similarities to cold panniculitis and perniosis that histopathologically resembles lupus. JAMA Dermatol. 2013 Nov;149(11):1314-8. doi: 10.1001/jamadermatol.2013.6302. PMID: 24026341.

6. Tran D, Riley J, Xiao A, Jay S, Shitabata P, Nami N. Ice pack-induced perniosis: a rare and underrecognized association. Cutis. 2018 Nov;102(5):E24-E26. PMID: 30566562.

7. Sabeti S, Birmingham SW, Urso B, Nguyen MO, Doan LT, Rojek NW. A case of ice-pack dermatosis in a patient with chronic back pain and review of the literature. Int J Dermatol. 2023 Jun;62(6):e367-e369. doi: 10.1111/ijd.16258. Epub 2022 May 4. PMID: 35506198.

8. Stewart JR, Swanson LA, Drage LA, Comfere NI. Ice-pack dermatosis of the buttocks. Int J Dermatol. 2020 Nov;59(11):e418-e419. doi: 10.1111/ijd.14942. Epub 2020 May 20. PMID: 32436222.

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