ALLERGIC SKIN DISEASE (URTIKARIA, ANGIOEDEMA)

7/30/2019 ALLERGIC SKIN DISEASE (URTIKARIA, ANGIOEDEMA)

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ALLERGIC SKIN DISEASE

(URTIKARIA, ANGIOEDEMA)

LABORATORY TEST

GROUP MEMBERS OF SGD B3:

CITRA GADING 0902005010

NI PUTU SUNTIAWATI 0902005053

KEVIN LEORNARD SURYADINATA 0902005087

YUDI ARTHA 0902005132

UVARANI VEERASAMY 0902005221

NUR ILYANA BINTI JAMALUDIN 0902005211

JAGTISH RAJENDRAN 0902005200

POTHANANTHA RAJA PATHMANATHAN 0902005189

SHANTINE THARUMANATHAN 0902005191

SEMESTER III

FACULTY OF MEDICINE

UDAYANA UNIVERSITY

2011


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CONTENT

NO. CONTENT PAGE

1 Chapter 1: Introduction

2. Chapter 2 : Content

2.1 Diagnostic Approach

2.2 Laboratory Studies

2.3 Diagnostic Tests

2.4 Specific findings

3. Chapter 3: Conclusion

4. References


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Introduction

Definition

Superficial itchy swellings of the skin due to transient plasma leakage from small blood vessels

are known as weals. Deeper swellings of the skin and alimentary tract are called angio-oedema.

These may be painful rather than itchy and tend to last longer. Weals and angiooedema

often coexist but either may occur alone. Most urticaria patients do not have systemic reactions

but, very rarely, physical urticarias may progress to anaphylaxis. Conversely, urticaria is often a

feature of anaphylactic and anaphylactoid reactions.[7]

There are two distinct types of urticaria called Ordinary Urticaria and Physical Urticaria.

Ordinary urticaria has two patternsAcute Urticaria and Chronic Urticaria.

Acute ordinary urticaria is often caused by an allergy to food, insect sting or

medication and can last between several hours and six weeks

Chronic ordinary urticaria is diagnosed if the rash persists for six weeks or longer, the

underlying cause is then usually not due to food allergies

All forms of urticaria may occur in association with deeper skin swelling or angioedema and

equally, angioedema may occur in isolation with no apparent urticaria. This depends on whether

we release histamine into the skin (urticaria), deeper tissues (angioedema) or both. Angioedema

swelling is most apparent in lax tissues around the eyelids, lips, tongue and genitals. This is also

referred to as Angioneurotic oedema and can be associated with Anaphylactic shock.[2]

What are hives (urticaria)?

Hives (medically known as urticaria) are red, itchy, raised areas of skin that appear in varying

shapes and sizes. They range in size from a few millimeters to several inches in diameter. Hives

can be round, or they can form rings or large patches. Wheals (welts), red lesions with a red

"flare" at the borders, are another manifestation of hives. Hives can occur anywhere on the body,

such as the trunk, arms, and legs. [3]


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One hallmark of hives is their tendency to change size rapidly and to move around, disappearing

in one place and reappearing in other places, often in a matter of hours. Individual hives usually

last two to 24 hours. An outbreak that looks impressive, even alarming, first thing in the morning

can be completely gone by noon, only to be back in full force later in the day. Very few, if any

other skin diseases occur and then resolve so rapidly. Therefore, even if you have no evidence of

hives to show the doctor when you get to the office for examination, he or she can often establish

the diagnosis based upon the history of your symptoms. Because hives fluctuate so much and so

fast, it is helpful to bring along a photograph of what the outbreak looked like at its worst. [3]

Swelling deeper in the skin that may accompany hives is calledangioedema. This may be seen

on the hands and feet as well as on mucous membranes (with swelling of the lips or eyes that can

be as dramatic as it is brief.)

[3]

The above table shows the Classification of urticaria subtypes (presenting with wheals and/or

angioedema)[8]
http://www.medicinenet.com/script/main/art.asp?articlekey=2253http://www.medicinenet.com/script/main/art.asp?articlekey=2253http://www.medicinenet.com/script/main/art.asp?articlekey=2253http://www.medicinenet.com/script/main/art.asp?articlekey=10681http://www.medicinenet.com/script/main/art.asp?articlekey=10681http://www.medicinenet.com/script/main/art.asp?articlekey=2253


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Content

Diagnostic Approach[4]

Detailed history is essential for diagnosis.

o Personal and family history

o Current or previous medications, herbals, or supplements

o Relationship to food exposures (ingestion, inhalation, contact)

o Relationship of potential physical triggers: e.g., cold, exercise, heat, sweating,

pressure, sun (or light) exposure

o Exposure to infectious processes: e.g., a respiratory virus, viral hepatitis,

infectious mononucleosis

o Occupational exposure to allergens or irritants

o Any recent insect sting or bite

o Contact exposure due to allergens, allergen exposure by inhalation

o Complete review of systems to include systemic diseases: e.g., autoimmune,

connective tissue and lymphoproliferative disorders

Physical examination, with special attention to:

o Thyroid enlargement (suggesting an autoimmune process and/or hormonal

dysregulation)

o Lymphadenopathy or hepatosplenomegaly (suggesting an underlying

lymphoreticular neoplasm)

o Joint, renal, central nervous system, skin, or serous surface abnormalities

(suggesting a connective tissue disorder)

o Dermographism suggests physical urticaria.

Cold, heat, and light tests are available for these respective physical

Further evaluation based on presenting findings

o IgE measurement for suspected IgE-mediated food, drug, or insect allergy

o Skin testing for detection of specific IgE antibody to inhalants (e.g., animal

danders, pollens, molds)

o Complement studies to exclude hereditary or acquired C1 esterase inhibitor

deficiency


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Laboratory Studies

Skin tests or radioallergosorbent assay test (specific IgE)[1]

o Selected allergy tests can be performed if food allergy or stinging insect

hypersensitivity is suspected. This may be helpful for some cases of acute

urticaria but is rarely helpful in the evaluation of chronic urticaria.Skin testing

can be performed to detect hypersensitivity to a limited number of antibiotics.

Testing for pollen or other inhalants is generally not helpful unless a severe

allergy may be causing the urticaria, such as a severe allergy to pollens, cats, or

latex (these may manifest as contact urticaria).

o Routine allergy testing with a large battery of screening tests is not recommended.

o

A few research centers perform an autologous serum skin test, but it is not a well-established procedure currently.

Screening laboratory studies[1]

o Which laboratory tests, if any, to order for routine screening is very controversial.

o Many specialists order only a few select screening studies for patients who have

chronic urticaria lasting at least 6 weeks with no apparent etiology.

o Some choose to perform no testing at all. Laboratory testing for acute urticaria is

not indicated, unless a particular medical condition is suspected.

o Common screening laboratory tests that may be ordered are as follows:

CBC with differential

Total eosinophil count

Sedimentation rate

Urinalysis

Liver function tests

o Evaluation of the complement system, including total hemolytic complement

(CH50), C3, and C4 should be considered in patients with prominent angioedema

(eg, C1 inhibitor deficiency causes angioedema but not urticaria) and may be of

benefit in patients with urticarial lesions lasting more than 24 hours. These tests

are of no value in patients with classic chronic urticaria.


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o Thyroid studies, including thyroid autoantibody levels (antimicrosomal,

antithyroglobulin) can be considered, particularly in women or in patients with a

family history of thyroid disease or other autoimmune diseases, although the

clinical significance of finding positive titers in a euthyroid individual is still

unclear.

o Order laboratory tests only if an abnormal result is found on the initial screening

tests or if a specific medical condition is suspected. Evaluation for possible occult

infection can be considered, but evidence that infections cause chronic urticaria is

limited.

o Other tests to consider if the history and physical examination findings are

suggestive of specific problems include the following:

Chemistry panel

Stool analysis for ova and parasites

H pylori workup

Hepatitis B and C workup

Sinus radiography (if symptomatic)

Antinuclear antibody (ANA)

Rheumatoid factor

Cryoglobulin levels

Other imaging studies

o Assays for serum histaminereleasing factors and evaluation for specific

autoantibodies (anti-IgE receptor/anti-FcR1 and anti-IgE) have been performed

by some research centers, and in-vitro assays geared toward measuring the

activity of anti-FcR1 autoantibodies can now be ordered through certain

commercial laboratories.Currently, 2 reference labs in the United States

commercially offer such a test: IBT Reference Laboratory (with the test referred

to as the CU IndexTM) and Clinical Reference Laboratories at National Jewish

Medical and Research Center (with the test referred to as the Anti-FcRI

antibody).The clinical role of a positive versus negative test finding on these

assays is still unclear, as current evidence does not make clear whether a positive

result should change management.


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Diagnostic tests[5]

Tests to consider:-

Tests to consider table for Urticaria and angio-oedema

Test Result

FBC with differential

Non-specific test that should be considered if performing alaboratory evaluation for chronic urticaria with or without

angio-oedema.

May provide evidence of occult infection, anaemia or findingssuggestive of chronic illness.

Also establishes a baseline for monitoring necessary with

some drug therapies.

may be normal orabnormal

complete metabolic panel

Non-specific test that should be considered if performing alaboratory evaluation for chronic urticaria with or withoutangio-oedema.

May provide evidence of chronic illness, such as hepatitis ornephritis.

Also establishes a baseline for monitoring necessary with

some drug therapies.

may be normal or

abnormal

urinalysis

Non-specific test that should be considered if performing a

laboratory evaluation for chronic urticaria with or withoutangio-oedema, especially in women.

May demonstrate asymptomatic bacteriuria, particularly infemale patients.

may show bacteriuria orpresence of white cells


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ESR

Non-specific test that should be considered if performing alaboratory evaluation for chronic urticaria with or withoutangio-oedema, especially if lesions are atypical.

Provides non-specific evidence of inflammation and/or apossible vasculitic component.

elevated

C-reactive protein

Non-specific test that should be considered if performing alaboratory evaluation for chronic urticaria with or without

angio-oedema, especially if lesions are atypical.

Provides non-specific evidence of inflammation and/or a

possible vasculitic component.

elevated

anti-IgE receptor antibody and related tests

Can only be ordered in specialised laboratories (can bereplaced with an autologous serum skin test depending on

availability).

Helps elucidate aetiology of chronic urticaria with or without

angio-oedema and often reassures both the patient and thephysician that there are no exogenous factors causing the

condition. The value of this test is controversial.

May provide evidence supporting an autoimmune aetiology of

chronic urticaria.

positive in autoimmune-related chronic urticaria

thyroid-stimulating hormone (TSH)

Should be accompanied by antithyroid antibodies test.

May reveal evidence supporting a diagnosis of

hypothyroidism and establishes a baseline value for potentialtherapy with thyroid replacement hormone.

elevated or normal

antithyroid antibodies

May help elucidate aetiology of chronic urticaria with orwithout angio-oedema. Should be accompanied by a TSH test.

Although the association of antithyroid antibodies and chronicurticaria is accepted, the value of this finding remains

controversial.

positive in Hashimotothyroiditis


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ANA

Only ordered if indicated by history and/or physicalexamination.

May provide evidence of underlying rheumatological disorder.

positive in many

rheumatological diseases

serum protein electrophoresis (SPEP)

Only ordered if indicated by history and/or physicalexamination.

May provide evidence of underlying haematologicalmalignancy.

may show increasedlevels of gamma

globulin

Helicobacter pylori antibody

Ordered when there is a history suggestive of oesophagealreflux or peptic ulcer disease.

positive in Helicobacter

pylori infection

skin prick testing for specific food allergens

Only ordered if history is suggestive of specific food allergies.Although controversial, it may also be ordered to reassure

patient and/or physician that food is not playing a role in

chronic urticaria. One must be aware of the possibility offalse-positive results, especially if a specific allergy is not

suggested by the history.

Positive results must be further evaluated with an elimination

diet and subsequent re-challenge of foods.

positive in urticaria

related to food allergy

in vitro IgE testing for specific food allergens

Can be used instead of percutaneous skin tests in patientsalready receiving antihistamines.

Only ordered if history is suggestive of specific food allergies.

Although controversial, it may also be ordered to reassurepatient and/or physician that food is not playing a role in

chronic urticaria. One must be aware of the possibility of

false-positive results, especially if a specific allergy is notsuggested by the history.

Positive results must be further evaluated with an eliminationdiet and subsequent re-challenge of foods.

positive in urticariarelated to food allergy


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skin biopsy

Sample is sent for standard staining and immunofluorescence

studies.

may show urticarial

vasculitis in setting ofatypical urticarial lesions

C4 level

Ordered in cases of angio-oedema without urticaria. A lowlevel is suggestive of either hereditary or acquired angio-

oedema.

decreased in hereditary

and acquired angio-oedema

C1-esterase inhibitor level

Ordered in cases with a high suspicion of hereditary angio-

oedema. A low level is highly suggestive of the diagnosis.

Rarely, patients can have normal levels of C1-esterase

inhibitor yet low function.


angio-oedema

C1-esterase inhibitor function

Given that rare patients can have normal levels of C1-esterase

inhibitor yet low function, this test is ordered in cases with a

high suspicion of hereditary angio-oedema, with a low levelconfirming the diagnosis.


angio-oedema

C1q levels

Ordered to help differentiate between hereditary and acquiredangio-oedema.

normal levels in

hereditary angio-oedema; low levels in

acquired angio-oedema


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The above table recommended diagnostic tests in frequent urticaria subtypes.[6]

Specific findings[4]

IgE-dependent

o No leukocytosis, elevated ESR, or hypocomplementemia

o With or without elevated total IgG

o With or without peripheral eosinophilia

o Allergen-specific IgE assay in serum (increased total IgE level or peripheral

eosinophilia)

Hereditary angioedema

o C1 inhibitor antigen (type 1) deficiency

o Normal C1 levels

o Decreased C4 and C2 levels (especially during attacks)

o Nonfunctional protein (type 2)

o Increased bradykinin level


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Acquired angioedema

o Decreased C1 function and C1q protein level

o Decreased C1 inhibitor, C4, and C2 levels


Angiotensin-converting enzyme inhibitorelicited angioedema


Conclusion

Hives (medically known as urticaria) are red, itchy, raised areas of skin that appear in

varying shapes and sizes.

Hives are very common and most often are not associated with a known cause.

Hives can change size rapidly and to move around, disappearing in one place and

reappearing in other places, often in a matter of hours.

Ordinary hives flare up suddenly and usually for no specific reason.

Physical hives are hives produced by direct physical stimulation of the skin.

Treatment of hives is directed at symptom relief while the condition goes away on its

own.

Antihistamines are the most common treatment for hives.

Hives typically are not associated with long-term or serious complications


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REFERENCES

1. Sheikh J,Najib U,Urticaria. 2010:emedicine.medscape.com2. Powell RJ, du Toit GL, Siddique N et al, BSACI guidelines for the management of

chronic urticaria and angio-oedema. Clin Exp Allergy 2007: 37; 631-650.

3.

Bolognia, Jean L., Joseph L. Jorizzo, and Ronald P. Rapini.Dermatology. 2nd ed. Spain:Mosby, 2008.

4. Zuraw BL: Clinical practice. Hereditary angioedema.N Engl J Med359:1027, 2008[PMID:18768946]

5. http://bestpractice.bmj.com/best-practice/monograph/844/diagnosis/tests.html6. Zuberbier et al. EAACI/GA2LEN/EDF guideline: definition, classification and diagnosis

of urticaria Allergy 2006: 61: 316320

7. C.GRATTAN, S.POWELL* AND F.HUMPHREYS, Management and diagnosticguidelines for urticaria and angio-oedema, British Journal of Dermatology 2001; 144:708714

8. Zuberbier et al. EAACI/GA2LEN/EDF guideline: definition, classification and diagnosisof urticaria Allergy 2009: 64: 14171426
http://www.unboundmedicine.com/medline/ebm/record/18768946/full_citationhttp://bestpractice.bmj.com/best-practice/monograph/844/diagnosis/tests.htmlhttp://bestpractice.bmj.com/best-practice/monograph/844/diagnosis/tests.htmlhttp://www.unboundmedicine.com/medline/ebm/record/18768946/full_citation

ALLERGIC SKIN DISEASE (URTIKARIA, ANGIOEDEMA)

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