Cold panniculitis M79.86

Haxthausen 1941

Localized inflammation of the subcutaneous fatty tissue as a result of external influences such as cold or wetness. Typically, 2 to 3 days (more rarely delayed after 10-14 days) after local hypothermia, deeply cutaneous, succulent, painful lumps in the fatty tissue appear.

Newborns have a higher content of saturated fatty acids in the adipose tissue, especially palmitic and stearic acid. This age-related physiological peculiarity causes an increased solidification point (solidification point of a phase transformation). This peculiarity leads to a premature solidification of the adipose tissue, to the precipitation of lipid needles (needle-shaped clefts) and to an inflammatory local reaction on local cooling. The triggering of a cold panniculitis is thus obligatory in newborns (example: popsicle panniculitis = ice-on-a-stick panniculitis)! The fetal adipose tissue reduces in the course of the first year of life.

An analogous mechanism is also discussed in sclerema neonatorum and adiponecrosis subcutanea neonatorum.

In adults, the cause is unclear apart from direct exposure to cold (Reiter's panniculitis).

Cryoproteins have been detected in isolated cases.

Infants, young girls, less often obese women.

Mainly chin region (double chin), mammae, nates, outer thigh areas (equestrian panniculitis, aggravated by immobile sitting in the cold and wearing tight riding breeches)

Lobular panniculits with mixed infiltrates in the deep dermis and underlying fatty tissue. Here wall thickened, dilated vessels bulging with erythrocytes, dense infiltrate sheaths of lymphocytes and eosinophil granulocytes. Neutrophil granulocytes and histiocytes may be present concomitantly. Infiltrates also show up periadnexially around sweat glands and perineurally. Adipocytes ruptured. Detection of foam cells and micropseudo-lipid cysts.

• Clinical differential diagnosis:
• Perniones: Acral localized, doughy, usually clearly painful plaques or nodules. Mostly distinct acrocyanosis. The duration of the changes varies, ranging from hours to several days to weeks. Itching or burning may occur when warming up.
• Lupus panniculitis: Rare; usually several, often symmetrically localized, firm, sharply defined mostly symptomless, subcutaneous nodules or plaques. The overlying skin is discrete red or brown-red and may be slightly retracted. No clear cold trigger.
• Histological differential diagnoses:
• Erythema nodosum: As in cold panniculitis there is septal panniculitis. Initial: infiltration by neutrophil granulocytes in the fatty tissue septum, formation of Miescher's radial nodules; edema, macrophages, foam cells. Full-stage: granulomatous reaction of the adipose tissue; non-specific concomitant reaction in the reticular dermis; adipose tissue septums are fibrotically transformed.
• Adiponecrosis subcutanea neonatorum: Occurs only in newborns (thus clinically excluded!). Lobular panniculitis with fat tissue necroses. Mostly alternating dense infiltrates of cluster-like arranged foam cells and multinucleated giant cells with radial needle shaped clefts. Fibroblasts in varying numbers. The needle-like, optically empty spaces correspond to dissolved fatty acid crystals. Rare occurrence of calcifications.

In case of severe symptoms and cold weather non-steroidal anti-inflammatory drugs, e.g. acetylsalicylic acid (e.g. Aspirin) 1.5-2.0 g/day p.o. or diclofenac (e.g. Voltaren Tbl./Supp.) initially 150 mg, as maintenance dose 100 mg/day p.o..

CAVE: No ASA in children under 15 years of age due to risk of Reye's syndrome!

• The 28-year-old (slim) rider noticed burning and painful skin changes on the extensor sides of both thighs for the first time in winter, which healed after 2-3 weeks without any therapy. 1 year later in November, another general assembly, which did not heal this time, but recurred constantly.
• Findings: Numerous flat and reticular blue-red erythema and several circumscribed 1.0-3.0 cm large, slightly painful red nodules were found on the extensor sides of both thighs and on both glutaeas.
• Laboratory: o.p.B. Insbes. no cryoglobulins, no CRP elevation, no ANA, no thyroid glands AK.
• Histology: Septolobular panniculits with mixed infiltrates in the deep dermis and underlying fatty tissue. Isolated neutrophil granulocytes and histiocytes. Lympho-histiocyte infiltrates were also found periadnexially around sweat glands and perineurally.
• Course: After consequent avoidance of cold exposure (wearing of thermal underwear and heat insulating breeches) the panniculitic symptoms healed completely without further therapy.

1. Haxthausen H (1941) Adiponecrosis e frigore. Br J Dermatol 33: 83-89
2. Huang FW et al (2008) Popsicle panniculitis in a 5-month-old child onsystemic
   prednisolone therapy. Pediatric dermatol 25:502-503.
3. Hultcrantz E (1986) Haxthausen`s disease. Cold panniculitis in children. J Laryngol Otol 100: 1329-1332
4. Lipke MM et al (2015) Cold panniculitis: delayed onset in an adult. Cutis 95:21-24
5. Macdonald JM et al (2003) Lymphedema, lipedema, and the open wound: the role of compression therapy. Surg Clin North Am 83: 639-658
6. Mooser G (2001) Cold panniculitis--an unusual differential diagnosis from aluminium allergy in a patient hyposensitized with aluminium-precipitated antigen extract. Contact dermatitis 44: 368
7. Rajkumar SV et al (1976) Popsicle panniculitis of the cheeks. A diagnostic entity caused by sucking on cold objects. Clin Pediatr 15: 619-922
8. Runge J et al (2011) Cold panniculitis. Act Dermatol 37: 184-185
9. Ter Poorten JC et al (1995) Cold panniculitis in a neonate. J Am Acad Dermatol 33: 383-385
10. Wagner G et al (2010) The cold panniculitis in female riders. Act Dermatol 36: 403-407