Cold Panniculitis in Children
L. B. Lowe, Jr., MD, New York
IN 1902, Carl Hochsinger described a
hardening of tissue in the submental re-
gion in children, related to cold exposure.1
His patients were between 4 and 10 years
old. After exposure to unusually cold
weather, they developed a tender, slightly
erythematous, well-demarcated induration
of the submental subcutaneous tissue.
Most of his patients had an abundance of
subcutaneous fat in the area. The indura-
tion gradually resolved spontaneously in
two to three weeks. Hochsinger compared
the lesions to those of subcutaneous fat
necrosis of the newborn, and observed a
similar lesion after prolonged application
of an ice bag to the thigh of an 8-year-old
boy. In only one instance was the cheek
involved.
In 1941, Haxthausen described five ad-
ditional cases, four in children aged 6
months to 3 years, and one in a 17-year\x=req-\
old girl.2 His patients all had conspicuous
involvement of the cheeks, and the oldest
girl had evidence of second degree frost-
bite, indicating a particularly severe cold
exposure. A biopsy of one of the lesions
showed normal epidermis and dermis, but
necrosis, fibrosis, and lymphocytic infil¬
tration of the subcutaneous fat. He, too,
compared this condition to neonatal subcu¬
taneous fat necrosis, and emphasized the
similarity of the microscopic pictures.
In 1966, two further studies appeared in
the dermatological literature, one of an
8-month-old girl and a 5-month-old boy,3
and the other of a 6-month-old boy.4 In
these patients, the presenting lesion was
reproduced on the volar aspect of the
Received for publication Oct 23, 1967.
From the departments of dermatology and pedi-
atrics, Cornell University Medical College, New
York.
Reprint requests to 1300 York Ave, New York
10021 (Dr. Lowe).
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forearm by ice application. These lesions
could not be reproduced in controls under
the same conditions, and in the last men¬
tioned patient the exposure time required
to produce the lesion gradually increased
until by age 22 months even 15 minutes of
ice exposure failed to elicit an induration.
In these children extensive laboratory
examinations, including hemogram, uri¬
nalysis, venereal disease research labora¬
tory test for syphilis (VDRL), serum
protein electrophoresis, cold agglutinins,
cold hemolysins, cryoglobulins, cryofi-
brinogens, antistreptolysin (ASO) titer,
lupus erythematosus (LE) factor coagu¬
lation studies, immunoelectrophoresis, and
sedimentation rate, were entirely normal.
Biopsies of the induced plaques showed
panniculitis.
Discussion of these cases and the two to
be presented herein with several pedia¬
tricians made clear that similar patients
are encountered frequently by pediatri¬
cians practicing in where there is a
areas
cold season. The association with cold and
spontaneous resolution are well known to
them. Since inspection of two major pedi¬
atrie texts 5,e revealed no mention of this
rather common pediatrie problem, and
since most studies of it have been in the
dermatological literature, the following
cases are presented.
Report of Cases
Case 1.—A 7-month-old Negro boy was seen
in the New York Hospital Dermatology Clinic in
February 1967, with the presenting complaint of
a "growth" in the left cheek. Two days after
having been out for several hours on a par¬
ticularly cold and windy day, he had developed
erythema and swelling of the left cheek, which
was firm and nontender (Fig 1). Physical exami¬
nation revealed a chubby child with well-
developed fat pads in both cheeks, and a 1 X 1
 cm firm mass in the left cheek which was
to the skin but freely movable over the un¬
derlying tissue. History and physical examina¬
tion were otherwise unremarkable. An ice cube
was applied to the volar aspect of the left fore¬
arm for two minutes. Within 48 hours, an ery-
thematous indurated plaque similar to the one
in the cheek was present at the site of ice ap¬
plication. The test plaque resolved spontaneously
over a period of two weeks, while the facial
plaque required two months for resolution. An
attempt to induce a lesion on the forearm with
five minutes of ice application was unsuccessful
when the patient had reached the age of 11
months.
Case 2.—A 3-year-old Negro girl was seen in
the New York Hospital Dermatology Clinic in
March 1987, with the presenting complaint of
"swelling" of the cheeks. Two days after several
hours of being out in 10 to 20 F weather, she
had developed tender red swellings of both
cheeks. Physical examination revealed erythema
of both cheeks with a well demarcated 1.5 2
cm indurated mass in the right cheek. In addi¬
tion, there was a well-demarcated linear indura¬
tion within the submental fat pad. History and
physical examination were otherwise unremark¬
able. An ice cube was applied to the volar sur-
Fig 1.—Closeup of plaque in left cheek. Note
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fixed faces of the left forearms of the patient and her
4-year-old sister. The latter developed only
transient erythema, while the patient within
two days had developed an erythematous indu¬
rated plaque at the site of ice application. This
plaque was biopsied two days after the ice had
been applied. Reapplication of ice for ten min¬
utes failed to reproduce the lesion three months
later. The plaques on both forearm and face
resolved within two weeks.
Materials and Methods
The biopsy specimen was bisected. One half
was fixed in 10% buffered formaldehyde (Forma¬
lin) and paraffin sections were stained with
hematoxylin and eosin. The other half was frozen
at —30 C in a cryostat and sectioned, air dried,
postfixed in formol-calcium and stained with oil
red O in carbowax 400.7 Sections were stained
after stabilization at 25, 50, and 75 C and com¬
pared with identically processed specimens of
subcutaneous fat from a newborn, a 5-week-old,
a 10-week-old, and a 20-year-old adult.
Results
The epidermis and dermis appeared
normal, pathologic changes being confined
sharp demarcation and follicular prominence (case 1).
 to the subcutaneous fat (Fig 2). Many of ly faint in the patient andin the three
the adipose cells were disrupted with a infant controls, while adult fat stained
loss of the usual mass of circles appear¬ moderately deeply at that temperature. At
ance of the fat. Adipose cells and larger 50 C the fat of the patient and of the three
cystic areas were surrounded by histio- infant controls stained only moderately,
cytes with smaller numbers of lympho¬ while adult fat stained intensely. At 75 C
cytes and a few neutrophils (Fig 3). all specimens stained intensely.
There was endothelial swelling of vessel
walls but no frank vasculitis. Connective Comment
tissue septae throughout the fat appeared Fat necrosis from cold is not unique to
somewhat thickened. No foam cells or infants and children. Instances have been
giant cells were present, nor were there reported in a 17-year-old girl,2 a 28-year-
crystals such as those seen in neonatal old woman,8 and a 35-year-old woman.9
subcutaneous fat necrosis. In the first case, exposure was severe
Oil red O staining at 25 C was extreme- enough to produce bullae, in the second
there were cryofibrino-
Fig 2.—Normal dermis with underlying panniculitis (hematoxylin and gens, and in the third there
eosin, 25) (case 2).
were two hours of ice ex¬

posure. The cases pre¬

viously reported in infants
and children and the two
reported here resulted
from cold exposure in no

way extraordinary. This,

coupled with the common
appearance of cold pannic¬
ulitis in pediatrie as op¬
posed to adult practice,
would appear to indicate
that infants and children
do possess a unique sus¬
ceptibility to this condi¬
tion. The work of Lemez 10
demonstrates that the ease
with which fat necrosis
can be produced by cold is

inversely related to the

age of the subject. This is
very likely a reflection of
the trend of subcutaneous
fat to become more un-
saturated with a higher
solidification point with
aging.11·12
Oil red O staining of fat
becomes more intense as
the fat becomes more liq¬
uid. It can be inferred from
the data presented above
that at 25 and 50 C the fat

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 Fig 3.—Infiltration largely composed of histiocytes, rupture of fat cells (hematoxylin and eosin,
X 100) (case 1).
of the patient and three infant controls
was less liquid than that of the adult
control, while at 75 C the physical state of
all four specimens was comparable.
No data are available on the lipid analy¬
sis of subcutaneous fat of children with
cold panniculitis. However, the evidence
presented above indicates that the unique
susceptibility of young patients to cold
panniculitis might best be explained by
the persistence of infantile fat composition
and its greater ease of solidification. The
limitation to the cheeks is a result of cloth¬
ing patterns and abundance of fat in the
cheeks. The lack of cases under 5 months
of age reflects the well-founded reluctance
of parents to expose a very young infant
to the elements; it is known that when
such young infants are accidentally ex¬
posed to cold, generalized induration fre¬
quently develops.13
It is not clear why cold panniculitis
only develops in a minority of comparable
patients exposedto the same conditions.
Duncan et al4 propose a delayed hyper-
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sensitivity the basis of the delayed na¬
on
ture of the reaction and failure to dem¬
onstrate passive transfer, cryoproteins or
prophylactic value of antihistamines. It is
well established that variations in diet af¬
fect both the composition of subcutaneous
fat and the ease with which it can be
damaged by cold.14 Perhaps variation in
dietary content of saturated as opposed to
unsaturated fats might be an etiologic
factor. Further understanding of this con¬
dition awaits biochemical analysis of the
involved fat.
Summary
The literature of cold panniculitis is
reviewed and two additional cases are
presented with histopathology and results
of oil red O staining for fat of one case
and four normal controls. It is stressed
that cold panniculitis is far more common
in pediatrie practice than the paucity of
reported cases would indicate. Immaturity
of the subcutaneous fat with excessive
amounts of saturated fatty acids and a
 higher solidification point is postulated
the most likely etiology.
This investigation was supported by a training
grant Tl-AM-5463 from the National Institutes of
Health, US Public Health Service.
References
1. Hochsinger, C.: \l=U"\bereine akute kongelative
Zellgewebsverh\l=a"\rtungin der Submentalregion bei
Kindern, Mschr Kinderheilk 1:323-327, 1902.
2. Haxthausen, H.: Adiponecrosis e frigore, Brit
J Derm 53:83-89, 1941.
3. Rotman, H.: Cold Panniculitis in Children,
Arch Derm 94:720-721, 1966.
4. Duncan, W.C.; Freeman, R.G.; and Heaton,
C.L.: Cold Panniculitis, Arch Derm 94:722-724, 1966.
5. Holt, L.E., Jr., et al: Pediatrics, ed 13, New
York: Appleton-Century-Crofts, Inc., 1962.
6. Nelson, W.E. (ed.): Textbook of Pediatrics,
ed 8, Philadelphia: W. B. Saunders Co., 1964.
7. Zugibe, F.T., et al: Carbowax 400: A New
Solvent for Oil Red O and Sudan IV for staining
as Carbowax-Embedded and Frozen Sections, Stain
Techn 34:33-37, 1959.
8. Solomon, L.M., and Beerman, H.: Cold Pan-
niculitis, Arch Derm 88:897-900, 1963.
9. Cohen, I.: Traumatic Fat Necrosis of the
Breast, JAMA 80:770-771, 1923.
10. Lemez, L.: Beitrag zur Pathogenese der sub-
cutanen Fettgewebsnekrose Neugeborener (sog.
Sclerodermia neonatorum) an der Hand einer
K\l=a"\ltereaktiondes subcutanen Fettgewebes bei
Neugeborenen und jungen S\l=a"\uglingen,Z Kinder-
heilk 46:323-369, 1928.
11. Smith, C.S.: Chemical Changes in the Sub-
cutaneous Fat in Sclerema Neonatorum, J Cutan
Dis 36:436-440, 1918.
12. Hirsch, J.: "Fatty Acid Patterns in Human
Adipose Tissue," in Handbook of Physiology, sec-
tion 5: The Adipose Tissue, Baltimore: The Wil-
liams & Wilkins Co., 1965, p 181-190.
13. Bower, B.D., et al: Cold Injury in the New-
born, Brit Med J 1:303-309, 1960.
14. Adams, J.E., et al: Experimental Production
of Subcutaneous Fat Necrosis by General Hypo-
thermia, Surg Forum 5:556-563, 1954.

FACT VERSUS FANCY

At all events, in defense of the case report and conclusions based on meager data,
"In science one must choose between being absolutely safe but entirely sterile on the one
hand and on the other having the courage to think beyond one's facts. The conclusions of
the latter method may require revision; it will certainly entail some mistakes and is bound
to expose one to the ridicule or suspicion by those who would rather be safe than con¬
structive. Nevertheless most of the great discoveries of science have been made with the
inductive rather than the deductive method."—Source unknown.

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