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URTICARIA

�ِ �Dr Anahita ValiDermatologist & venereologist

Urticaria is a transient element

Is it transient???Less than 24 hours

MARKING AROUND THE LESIONS

Urticaria is a cutaneous reaction pattern (from the Latin urtica, nettle,]

commonly referred to as hives,

is a kind of skin rash notable for pale red, raised, itchy bumps. Hives might also cause a burning or stinging sensation. Hives are frequently caused by allergic reactions; however, there are many nonallergic causes.

Why transient & itching???

How Long???

Most cases of hives lasting less than six weeks (acute urticaria) are the result of an allergic trigger.

Chronic urticaria (hives lasting longer than six weeks) is rarely due to an allergy.

Clinical findings

Distribution Any body site

Morphology Central, oedematous plaques without scale

(a wheal) and surrounding redness (a flare)  Annular lesions result from central clearing  Lesions vary in size, some can be very large

Can be associated with angioedema, and much less commonly anaphylaxis. Anaphlaxis is defined by a progressive reaction with rash, breathing difficulties and cardiovascular compromise. The most common causes of anaphylactic reactions are in the following order: Food allergy Drugs  Stings / bites 

slightly raised, no scale

The majority of chronic hives cases have an unknown (idiopathic) cause.

In perhaps as many as 30–40% of patients with chronic idiopathic urticaria, it is caused by an autoimmune reaction.

Acute viral infection is another common cause of acute urticaria (viral exanthem).

Less common causes of hives include friction, pressure, temperature extremes, exercise, and sunlight.

What is the differences?

Wheals (raised areas surrounded by a red base) from urticaria can appear anywhere on the surface of the skin. Whether the trigger is allergic or not, a complex release of inflammatory mediators, including histamine from cutaneous mast cells, results in fluid leakage from superficial blood vessels. (well-demarcated,erythmatousus) Wheals may be pinpoint in size, or several inches in diameter.itching

Angioedema is a related condition (also from allergic and nonallergic causes), though fluid leakage is from much deeper blood vessels in the subcutaneous or submucosal layers.(poorly –defined borders) Usually mucosa, lips, palm &soles/lids/genitalia/tongue/larynx/GI/GU/painful

Hives during life: 20-25% All age groups Acute urticaria more

common in children & young adults

Chronic urticaria is more prevalent in adults/F>M

How many percent of Pts are free of chronic urticaria after 1 years???

After 5 years??? & after 20 years???

Conclusion: If urticaria associated with angioedema is more persistent.

Urticaria alone :40% Urticaria &

angioedema :49% Angioedema alone:11% Some of the more severe

chronic cases have lasted more than 20 years. A survey indicated chronic urticaria lasted a year or more in more than 50% of sufferers and 20 years or more in 20% of them.

Morbidity depends on the severity and duration of the condition. One study found that urticaria patients can have as much psychologic, social, and occupational distress as patients who are awaiting triple coronary artery bypass surgery.

Urticaria can also be classified by the purported causative agent. Many different substances in the environment may cause urticaria, including medications, food and physical agents.

After contact with a Conifer

Management Avoid triggers Use non-sedating antihistamines PRN Occasionally a short course of oral steroids (prednisolone) may

be needed Patients with anaphylaxis will often be diagnosed at an accident and

emergency department. Such patients should be provided with two Epipens and relevant advice on how to manage an attack including how to use an Epipen

Some patients will benefit from a referral to an immunologist / paediatrician, for example: Patients with moderate-severe reactions to eggs Patients with nut allergies, who often have multiple allergies and may

require further investigations Other cases of life-threatening reactions

Drug-induced urticaria Drugs that have caused allergic

reactions evidenced as urticaria include dextroamphetamine,aspirin, ibuprofen, penicillin, clotrimazole, sulfonamides, anticonvulsants, cefaclor and antidiabetic drugs. The antidiabetic sulphonylurea glimepiride (trade name Amaryl), in particular, has been documented to induce allergic reactions manifesting as urticaria. Drug-induced urticaria has been known to have an effect on severe cardiorespiratory failure.

Infection or environmental agent Urticaria can be a complication and

symptom of a parasitic infection, such as fascioliasis (Fasciola hepatica) and ascariasis (Ascaris lumbricoides).

The rash that develops from poison ivy, poison oak, and poison sumac contact is commonly mistaken for urticaria. This rash is caused by contact with urushiol and results in a form of contact dermatitis called urushiol-induced contact dermatitis.

Urushiol is spread by contact, but can be washed off with a strong grease- or oil-dissolving detergent and cool water and rubbing ointments.

Dermatographic urticaria

"skin writing") Hives caused by stroking the skin (often linear in

appearance) are due to a benign

condition in 4–5% of the population usually becomes evident

soon after the scratching, and disappears within 30 minutes.

Dermatographism is the most common form of a subset of chronic hives, acknowledged as "physical hives

It stands in contrast to the linear reddening that does not itch seen in healthy people who are scratched. In most cases, the cause is unknown,

although it may be preceded by a viral infection, antibiotic therapy,

or emotional upset. Dermographism is diagnosed by taking a tongue

blade and drawing it over the skin of the arm or back. The hives should

develop within a few minutes. Unless the skin is highly sensitive and reacts continually, treatment is not needed. Taking antihistamines can reduce the response in cases that are annoying

to the patient.

Pressure or delayed pressure urticaria

This type of urticaria can occur right away, precisely after a pressure stimulus or as a deferred response to sustained pressure being enforced to the skin. In the deferred form, the hives only appear after about six hours from the initial application of pressure to the skin.

Under normal circumstances, these hives are not the same as those witnessed with most urticariae. Instead, the protrusion in the affected areas is typically more spread out. The hives may last from eight hours to three days. The source of the pressure on the skin can happen from tight fitted clothing, belts, clothing with tough straps, walking, leaning against an object, standing, sitting on a hard surface, etc. The areas of the body most commonly affected are the hands, feet, trunk, abdomen, buttocks, legs and face. Although this appears to be very similar to dermatographism, the cardinal difference is that the swelled skin areas do not become visible quickly and tend to last much longer. This form of the skin disease is, however, rare.

Treat your pts based on pathophysiology

PMN-RICH URTICARIA LYMOCYTE & MAST-CELL RICH URTICARIA

urticarial vasculitis Individual hives that are painful, last more than 24 hours leave a bruise as they heal are more

likely to be a more serious condition

Cholinergic or stress

Cholinergic urticaria (CU) is one of the physical urticaria which is provoked during sweating events such as exercise, bathing, staying in a heated environment, or emotional stress. The hives produced are typically smaller than classic hives and are generally shorter-lasting.

Multiple subtypes have been elucidated, each of which require distinct treatment.

Sudden death after diving

Cold-induced is caused by exposure of the skin to extreme cold, damp and windy conditions; it

occurs in two forms. The rare form is hereditary and becomes evident as hives all over the

body 9 to 18 hours after cold exposure. The common form of cold urticaria demonstrates itself with the rapid

onset of hives on the face, neck, or hands. Cold urticaria lasts for an average of five to six years. The population most affected is young adults, between 18 and 25 years old. Many people with the condition also suffer from dermographism and cholinergic urticaria.

Severe reactions can be seen with exposure to cold water; swimming in cold water is the most common cause of a severe reaction. This can cause a massive discharge of histamine, resulting in low blood pressure, fainting, shock and even loss of life. Cold urticaria is diagnosed by dabbing an ice cube against the skin of the forearm for 1 to 5 minutes. A distinct hive should develop if a patient suffers cold urticaria. This is different than the normal redness that can be seen in people without cold urticaria.

Patients with cold urticaria need to learn to protect themselves from a hasty drop in body temperature. Regular antihistamines are not generally efficacious. One particular antihistamine, cyproheptadine (Periactin), has been found to be useful. The tricyclic antidepressant doxepin .Finally, ketotifen, which keeps mast cells from discharging histamine, has also been employed with widespread success.

Heat-induced urticaria This rare form of urticaria is

triggered by the continued application of heat on the skin.

Hives begin to appear within two to five minutes on the area of the skin exposed to heat.

Do not last more than an hour.

Solar urticaria This form of the disease occurs on areas of the

skin exposed to the sun; the condition becomes evident within minutes

of exposure. After the individual is no longer exposed to the sun, though, the condition starts to weaken within a few minutes to a few hours, and hardly ever lasts longer than 24 hours.

Solar urticaria is classified into six different types, depending upon the wavelength of light involved.

Since glass absorbs light with a wavelength of 320 nm and below, people suffering from solar urticaria in response to wavelengths of less than 320 nm are protected by glass.

Water urticaria rare, and occurs upon contact with water. The

response is not temperature-dependent and the skin appears similar to cholinergic form of the disease. The appearance of hives is within one to 15 minutes of contact with the water, and can last from 10 minutes to two hours. The hives that last for 10 to 120 minutes do not seem to be stimulated by histamine discharge like the other physical hives. Most researchers believe this condition is actually skin sensitivity to additives in the water, such as chlorine.

diagnosed by dabbing tap water and distilled water to the skin and observing the gradual response. Aquagenic urticaria is treated with capsaicin (Zostrix) administered to the chafed skin. This is the same treatment used for shingles. Antihistamines are of questionable benefit in this instance, since histamine is not the causative factor.

Exercise urticaria hives, itchiness, shortness of breath and low blood pressure

five to 30 minutes after beginning exercise. These symptoms can progress to shock and even sudden death. Jogging is the most common exercise to cause EU, but it is not induced by a hot shower, fever, or with fretfulness. This differentiates EU from cholinergic urticaria

EU sometimes occurs only when someone exercises within 30 minutes of eating particular foods, such as wheat or shellfish. For these individuals, exercising alone or eating the injuring food without exercising produces no symptoms. EU can be diagnosed by having the patient exercise and then observing the symptoms. This method must be used with caution and only with the appropriate resuscitative measures at hand. EU can be differentiated from cholinergic urticaria by the hot water immersion test. In this test, the patient is immersed in water at 43°C (109.4°F). Someone with EU will not develop hives, while a person with cholinergic urticaria will develop the characteristic small hives, especially on the neck and chest

The immediate symptoms of this uncanny type are treated with antihistamines, epinephrine and airway support. Taking antihistamines prior to exercise may be effective. Ketotifen is acknowledged to stabilise mast cells and prevent histamine release, and has been effective in treating this hives disorder. Avoiding exercise or foods that cause the mentioned symptoms is very important. In particular circumstances, tolerance can be brought on by regular exercise, but this must be under medical supervision

Food urticaria

The most common food allergies in adults are shellfish and nuts. The most common food allergies in children are shellfish, nuts, peanuts, eggs, wheat, and soy. A less common cause is exposure to certain bacteria, such as Streptococcus species or possibly Helicobacter pylori.

Vibratory angioedema & urticaria

This very rare form of angioedema develops in reply to contact with vibration. In vibratory angioedema, symptoms develop within two to five minutes after contact with vibration and dissolve after about an hour. Patients with this disorder do not suffer from dermographism or pressure urticaria. Vibratory angioedema is diagnosed by holding a vibrating device such as a laboratory vortex machine against the forearm for four minutes. Speedy swelling of the whole forearm extending into the upper arm is also noted later. The principal treatment is avoidance of vibratory stimulants. Antihistamines have also been proven helpful.

 Pathophysiology

The skin lesions of urticarial disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis, and resulting in an edema which persists until the interstitial fluid is absorbed into the surrounding cells.

Urticaria is caused by the release of histamine and other mediators of inflammation (cytokines) from cells in the skin. This process can be the result of an allergic or nonallergic reaction, differing in the eliciting mechanism of histamine release

Autoimmune urticaria

In the past decade, many cases of chronic idiopathic urticaria have been noted to be the result of an autoimmune trigger. For example, roughly one-third of patients with chronic urticaria spontaneously develop autoantibodies directed at the receptor FcεRI located on skin mast cells. Chronic stimulation of this receptor leads to chronic hives. Patients often have other autoimmune conditions, such as autoimmune thyroiditis.

Nonallergic urticaria Mechanisms other than allergen-antibody

interactions are known to cause histamine release from mast cells. Many drugs, for example morphine, can induce direct histamine release not involving any immunoglobulin molecule.

Also, a diverse group of signaling substances, called neuropeptides, have been found to be involved in emotionally induced urticaria.

Dominantly inherited cutaneous and neurocutaneous porphyrias (porphyria cutanea tarda, hereditary coproporphyria, variegate porphyria and erythropoietic protoporphyria) have

been associated with solar urticaria. The occurrence of drug-induced solar urticaria may be associated with porphyrias. This may be caused by IgG binding, not IgE.

Nonallergic release of mediators A number of drugs, such as aspirin,

NSAIDs, opiates, succinylcholine, and certain antibiotics (eg, polymyxin, ciprofloxacin, rifampin, vancomycin, some beta-lactams) can cause urticaria by a nonallergic mechanism rather than by IgE-mediated hypersensitivity.

Certain foods or beverages, such as spoiled fish (scombroidosis), aged cheeses, or red wine, can contain histidine,

Certain venoms may cause urticaria. Radiocontrast media sensitivity is not

related to iodine, fish, or shellfish allergy.

Medical causes Urticaria has been reported with

infectious diseases. Viral infections associated with

acute urticaria include acute viral syndromes, hepatitis (A, B, and C), Epstein-Barr virus, and herpes simplex virus.

Streptococcal infection has been reported as the cause of 17% of acute urticaria cases in children.

Urticaria has also been reported with chronic parasitic infections. sinusitis, cutaneous fungal infections, Helicobacter pylori infection, or other occult infections

Urticaria associated with acute group A beta-hemolytic streptococci infection.

Hormonal causes Hormonal causes via endocrine

tumors or ovarian pathology are rare. Oral contraceptive use or changes in the menstrual cycle have been reported as a possible cause of urticaria: patients commonly report worsening of hives with the menstrual cycle. This may be hormonally mediated, and the cyclical use of analgesics should also be considered as a possible etiology

Dangerous causes of urticaria

Urticaria can be the presenting symptom of lymphoma, and a careful history and review of systems is important.

Rare causes of urticaria Cryoglobulinemias (eg, associated with hepatitis C, chronic lymphocytic leukemia)

Serum sickness Other immune complex–mediated

inflammation Systemic lupus erythematosus, rheumatoid

arthritis, juvenile rheumatoid arthritis, or other rheumatologic diseases (rare causes of urticaria)

Hypothyroidism and hyperthyroidism, although euthyroid patients with antithyroid antibodies (ie, vide infra) can be affected

Lymphoreticular malignancies (eg, chronic lymphocytic leukemia)

Pregnancy (ie, pruritic urticarial papules and

plaques of pregnancy [PUPPP]

Physical causes (physical urticaria)

Cold Pressure Vibration Cholinergic (triggered by

heat, exercise, or emotional stress)

Sunlight Water Dermographism (can

occur as an isolated condition)

Exercise

Hereditary angioedema (C1 inhibitor

deficiency) accounts for only 0.4% of cases of angioedema but is associated with a high mortality rate.

Dietary histamine poisoning

This is termed scombroid food poisoning. Ingestion of free histamine released by bacterial decay in fish flesh may result in a rapid-onset, allergic-type symptom complex which includes urticaria. However, the urticaria produced by scombroid is reported not to include wheals

Drug allergies Theoretically, almost any drug can

cause an allergic reaction thus, allergic reactions to a wide variety of drugs can occur.Antibiotics, such as penicillin, have been implicated most frequently.

Urticarial reactions to penicillin can occur as long as 14 days after a course of treatment has stopped. In this situation,

serum sickness may be present.

Stress and chronic idiopathic urticaria

Chronic idiopathic urticaria has been anecdotally linked to stress since the 1940s.[

A large body of evidence demonstrates an association between this condition and both poor emotional well-being and reduced health-related quality of life.

A recent study has demonstrated an association between stressful life events (e.g. bereavement, divorce, etc.) and chronic idiopathic urticaria and also an association between post-traumatic stress and chronic idiopathic urticaria.

Management Chronic urticaria can be difficult to treat. No

guaranteed treatments or means of controlling attacks are available, and some subpopulations are treatment-resistant, with medications spontaneously losing their effectiveness and requiring new medications to control attacks.

It can be difficult to determine appropriate medications, since some, such as loratadine, require a day or two to build up to effective levels, and the condition is intermittent and outbreaks typically clear up without any treatment.

Most treatment plans for urticaria involve being aware of one's triggers, but this can be difficult, since several forms of urticaria are known and people often exhibit more than one type. Also, since symptoms are often idiopathic, a clear trigger is often unknown. If triggers can be identified, then outbreaks can often be managed by limiting exposure to them.

Patient Education

Avoidance of known triggering factors is important, and patients with urticaria should be discouraged from scratching or irritating the skin when active lesions are present. Pressure urticaria may worsen the intensity of the rash; therefore, avoiding tight-fitting clothes may be helpful.

Allergy tests

Physicians can rarely determine any particular cause of disease for chronic urticaria.

In some cases, patients or doctors come to request regular extensive allergy testing over a long period of time in hopes of getting new insight.

No evidence shows regular allergy testing results in identification of a problem or relief for people with chronic urticaria.

Regular allergy testing for people with chronic urticaria is not recommended.

Antihistamines Antihistamines such as

diphenhydramine may be used.

The benefit of H2 receptor antagonists such as ranitidine is poorly supported by the evidence.

Other treatments Tricyclic antidepressants, such as doxepin, also are often potent H1 and H2 antagonists and may have a role in therapy, although side effects limit their use. For very severe outbreaks, an oral corticosteroid such as prednisone is sometimes prescribed. However, this form of treatment is controversial because of the extensive side effects common with corticosteroidsis not a recommended long-term treatment option.

For acute urticaria, some topical creams, such as hydrocortisone, fluocinonide, or desonide, to relieve itching. To boost relief for severe anaphylactic urticaria, a dermatologist will also administer steroid shots intramuscularly.

analogue of alpha-melanocyte-stimulating hormone called afamelanotide (for the treatment of solar urticaria, a type of urticaria that develops in response to exposure to specific wavelengths of light.

Therapy-refractory cases with urticaria may sometimes respond to unusual drugs, such as dapsone

A diet reduced in allergens like salicytes, grains, and the 8 most common food allergens may also help to reduce symptoms. Chronic Idiopathic Urticaria and treatment with an oligoantigenic diet. an allergen-restricted diet saw their urticaria decrease significantly or vanish entirely .

Acute urticaria induced by the use of trichazole only reacted to treatment by taking a very hot bath in water containing epsom salts and other vitamins and minerals known to induce exfoliation. Application of lemon juice brought temporary relief from itching and Epizone A cetomacrogol cream was the most effective topical application, after the heat treatment. [

]the anti-asthma drug omalizumab showed promise in relieving symptoms for patients with chronic idiopathic urticaria whose symptoms were not relieved with antihistamine treatment.

Anaphylaxis

Urticaria can be one of the first symptoms of a severe allergic reaction known as anaphylaxis.

swelling of your eyes, lips, hands and feet

narrowing of your airways which can cause breathing difficulties and wheezing

a feeling of impending doom as if something terrible is going to happen

Anaphylaxis should always be treated as a medical emergency. immediately dial 115 for an ambulance and tell the operator that you think anaphylaxis has occurred.

the moulds on any cheeses or aged foods apparently contain lots of histamines

avoid food containing vasoactive amines

بود اهل من چو كه هر و خورم مي من

بود سهل او نزد به من خوردن مي

دانست مي ازل ز حق من خوردن مي

بود جهل خدا علم نخورم مي گر

Contact urticaria Contact urticaria is

an allergic reaction to a substance that comes into contact with the skin (eg, an occupational exposure)

Latex in physicians ,nurses & dentist

Local urticaria on a patient with latex allergy who was touched with a latex glove.

Papular urticaria Insect bites Papular urticaria is a

variation of urticaria caused by insect bites the lesions may last longer than 24 hours.

Urticaria developed after bites from an imported fire ant.

Urticaria pigmentosa

Q & A

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