Cold panniculitis: Adverse cutaneous effect of whole-body cryotherapy

Introduction

Whole-body cryotherapy (WBC) involves exposure to extremely cold air (below -110°C) in an enclosed space for several minutes. It has been increasingly used in recent years as a treatment for muscle soreness after exercise, with many claiming it also has widespread cosmetic benefits.¹ However WBC does not have US Food and Drug Administration approval.² In addition, a 2015 Cochrane review determined there is insufficient evidence to support the claims of its benefits or safety.¹ Here we report a case of cold panniculitis that occurred after exposure to WBC.

Case report

A 47-year-old man with a medical history of hearing loss and autoimmune neutropenia presented for the evaluation of a diffuse papular eruption. Over the preceding 2 weeks, he received 8 WBC treatments in a cold chamber after exercise. During treatments, his face, hands, and feet were covered and he stood with his arms at his sides, thus also sparing the axillae from exposure. The eruption started on the lower extremities and proceeded to involve the trunk and upper extremities over the following days. He had occasional mild pruritus and mild tenderness of the abdominal lesions. The patient had no systemic symptoms associated with the skin eruption.

Physical examination found numerous erythematous, edematous pink papules, some coalescing into plaques, on the trunk, arms, and legs. The face, feet, hands, and axillae were spared (Figs 1 and 2).

Fig 1.

Clinical image of patient at initial presentation after exposure to WBC. Numerous erythematous, edematous pink papules and plaques are visible on the trunk, with a discrete cut-off at the border of the axillary vault. The axillae are spared.

Fig 2.

Clinical image of patient at initial presentation after exposure to WBC. Erythematous, edematous papules and plaques are seen on patient's right flank.

A punch biopsy found a superficial and deep perivascular mixed-cell infiltrate of lymphocytes, histiocytes, and neutrophils. The inflammatory infiltrate was most dense at the junction of the reticular dermis and subcutaneous fat and extended into fat lobules, where there was focal fat necrosis (Fig 3).

Fig 3.

Histologic image. There is a lymphohistiocytic infiltrate with neutrophils in the reticular dermis and superficial fat (Hematoxylin-eosin stain; original magnification: ×20.)

A diagnosis of cold panniculitis was made based on clinical presentation and histology. The patient's condition improved spontaneously without treatment within several weeks after discontinuation of WBC.

Discussion

WBC involves exposure to extremely cold dry air (below -110°C) in a specialized chamber or room, for 2 to 4 minutes.¹ It has been increasingly used within local gyms and athletic training facilities as a treatment for muscle soreness after exercise. However, a 2015 Cochrane review determined there is insufficient evidence to support improvement in self-reported muscle soreness or subjective recovery after exercise in physically active young men, with no evidence on its use in women or elite athletes. The review further highlighted the lack of evidence regarding its safety.¹ The US Food and Drug Administration has not cleared or approved any WBC devices.²

Several adverse events related to WBC have been reported, including the death of an employee at a cryotherapy center, who was reportedly using the chamber outside of business hours and was subsequently found dead in the chamber the next day.³ Case reports of adverse events after whole body cryotherapy sessions, including transient global amnesia⁴ and abdominal aortic dissection,⁵ are also documented.

The patient we present had diffuse erythematous, edematous pink papules with sparing of nonexposed areas after multiple WBC treatments. His presentation was most consistent with cold panniculitis—inflammation of the subcutaneous fat caused by cold exposure, commonly presenting as indurated erythematous papules, plaques, or nodules. The erythematous lesions typically become purpuric and less indurated over time. Residual hyperpigmentation may be seen for several months.⁶

Cold panniculitis is a self-limiting disorder, usually resolving in 2 to 3 weeks. No treatment is required beyond cessation of cold exposure and symptomatic relief.⁶ As WBC centers continue to proliferate, with many centers claiming widespread health benefits, it is important to be vigilant about potential adverse effects.