Urticaria is a dermatosis in which the primary eruption is a nettle rash (Fig. 5.7). The basic features of the wheal are swelling, itching, rapid appearance (minutes-hours) and rapid disappearance (1-24 hours). There are many types of urticaria of different etiopathogenesis and clinical course.
Dig. 5.7 Urticaria. Urticaria babel on the trunk
What is hives?
Urticaria is a condition resulting from an allergy to a given factor, but there are also non-allergic hives (resulting from the effects of the sun or cold water). In the course of the disease, blisters appear on the skin around which redness is visible. These blisters resemble changes that appear after nettle burn, hence the name of the ailment. In a large number of patients, urticaria is associated with angioedema, which is limited to the subcutaneous tissues such as the feet or eyelids. In addition, you can observe dermatographism, which is characterized by red discoloration on the skin.
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Urticaria – epidemiology
The frequency of individual clinical varieties of urticaria varies considerably. 75% of patients with urticaria suffer from the acute form. The data are imprecise as incidents of acute urticaria may not be recorded due to their rapid course and transient nature. In children, acute urticaria is most often associated with respiratory tract infections (bacterial, viral), urinary tract infections or gastrointestinal parasites (pinworms, lamellae, tapeworms). It is also associated with atopic dermatitis (55%) and food allergy (11%), especially in children under 3 years of age. In adults, the spread of acute urticaria is sometimes caused by food, drugs or additives.
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Types of hives
Acute allergic urticaria (Fig. 5.8 and 5.9)
Acute allergic urticaria is a condition whose primary eruption is hives. It is a very common dermatosis, especially in children. The cause is allergy to food (cow’s milk protein, eggs), sulfa drugs, antibiotics, painkillers, antipyretics, wasp and bee stings. Moreover, urticaria is often associated with atopic dermatitis.
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symptoms
Acute allergic urticaria has a sudden onset, usually mild, lasting several to several days. Eruptions are numerous, spread all over the body, accompanied by itching. Sometimes elevated temperature. The disease is rarely rapid in the form of anaphylaxis or laryngeal edema. Acute allergic urticaria sometimes becomes chronic.
How to heal?
The patient is given second-generation antihistamines orally in mild or moderate cases. Oral or injection glucocorticosteroids (severe).
Fig.5.8 Acute allergic urticaria after amoxicillin
Fig.5.9 Acute allergic urticaria after an analgesic drug
Acute non-allergic urticaria
Acute non-allergic urticaria affects adults more often than children. 81% of children under 2 years of age develop viral infections of the upper and lower respiratory tract, viral hepatitis A, B, C and Helicobacter pylori. In turn, in adults, the triggers are emotions, aspirin, codeine, morphine, contrast agents and foods that directly trigger histamine (fish, pineapples, wild strawberries).
symptoms
The course of acute non-allergic urticaria is usually mild and may last up to 6 weeks. The clinical picture is similar to acute allergic urticaria. No predilection sites.
Acute recurrent urticaria
Acute recurrent urticaria occurs periodically and is characterized by repeatedly occurring short-term exudations of urticarial wheals. This state may last for years. This variant is often associated with atopy, especially asthma-rhinitis-prurigo syndrome. Food allergens are the main cause.
symptoms
Lesions have a typical appearance and a fleeting nature of eruptions. There is also itching. The changes are located all over the body.
Diagnostics usually reveal an increased level of IgE, RAST. The disease should be differentiated from other types of urticaria.
Treatment
Second-generation antihistamines are administered orally in mild or moderate cases. Oral or injection glucocorticosteroids (severe). The disease is chronic and it likes to come back.
Serum sickness type urticaria
Serum sickness urticaria is a food or drug allergy (penicillin, streptomycin, sulfonamides, diphenylhydantoin). Anti-tetanus serum is the cause of the disease in 2,5% of patients treated.
symptoms
The first symptoms of urticaria appear 7-20 days after the allergens enter the system. There are hives, an increase in body temperature, Quincke’s edema, itching, joint pain, proteinuria. The course is often violent. Patients show general malaise.
The lesions are located all over the body.
Diagnosis and treatment
Diagnostics reveals whigh level of IgE, IgG. Glucocorticosteroids are the drug of choice. Average doses of prednisolone 30 mg / day for 7-10 days. Antihistamines are ineffective. The prognosis is good.
Chronic idiopathic (non-autoimmune) urticaria (Fig. 5.10)
Chronic idiopathic urticaria is a heterogeneous disease. Urticarial blisters are the primary bloom. They are sown at least 5 times a week. The disease lasts from 6 weeks to over 10 years.
The reasons
This type of urticaria accounts for approximately 50% of chronic urticaria. In 20-50% of patients it coexists with one of the types of physical urticaria. Middle-aged women are most often affected. The causative factor can be established in 30-47% of patients. Usually these are various types of infection (advanced caries).
symptoms
Irregular seeding of urticarial wheals appear as the only symptom of urticaria, or together with Quincke’s edema (rarely). The itching may worsen in the evening.
Treatment
XNUMXst and XNUMXnd generation antihistamines – orally (fully or partially effective). Steroids indicated in severe, resistant cases.
Fig.5.10 Chronic idiopathic urticaria. Ringed blisters
Autoimmune urticaria
The cause of autoimmune urticaria is the presence of antibodies (IgG1 and IgG3) that bind to IgE or IgE receptors on the surface of mast cells, basophils and Langerhans cells. This process releases histamine and other mediators.
symptoms
In the course of the disease, there are seedings of urticarial bubbles, which are sometimes more numerous and larger. They show significant expansion and itching.
Diagnostics
The diagnosis of the disease is carried out intradermal test with autologous serum, which, after injection, causes hives in 30-50% of patients. Significantly decreased activity of total complement (CH50), slightly increased level of antinuclear antibodies in 5-20% of patients, rheumatoid factor rarely present, thyroid antibodies (peroxidase, globulin, microsomal).
How to heal?
Arechine (chloroquine) is used in the treatment, antihistamines: non-sedative in the morning, sedative at night, doxepin, in severe course prednisolone (shortly), methotrexate, cyclosporine 2,5-5 mg / day, tacrolimus, PUVA, plasmapheresis.
Chronic allergic urticaria
This is a variety denied by many researchers.
Aspirin hives (Fig. 5.11)
Aspirin hives is hives caused by aspirin and food additives. The disease occurs mainly in adults of both sexes, and the incidence varies widely, ranging from 21% to 75% among patients with chronic urticaria. In children up to the age of 10, exceptionally.
Cause
The formation of urticaria is influenced by: Aspirin, non-steroidal anti-inflammatory drugs, food additives: benzoates, sulfates, monosodium glutamate, tetra-butyl-methoxyphenol, bis (tetra-butyl) -p-methoxyphenol, tartrazine azo dye, amaranth, sunset yellow. Sensitivity to the dye may occur in the absence of response to aspirin, so in some cases the diagnosis of aspirin urticaria may be difficult.
symptoms
The lesions do not differ from the clinical picture of idiopathic urticaria. The basis of diagnostics is a medical interview with the patient.
Treatment
An elimination diet is important and can be recommended by your GP. It consists in completely excluding cold cuts and canned food for a week. You can eat: beef, veal, pork, lean white cheese, vegetable oil, bread, rice, potatoes, sugar, salt. During the second week, the diet is not restricted. In the third week, the diet is recommended again.
We observe whether the elimination diet leads to the resolution of the eruptions and the provocation to their recurrence in the third week. Such regularity allows for the diagnosis of the discussed type of urticaria. After the diagnosis is made, the restrictive diet can be extended every other day, however, avoiding canned foods and fruit. The duration of the disease does not affect the effectiveness of dietary methods, which exceed 90%. In the presence of a psychosomatic factor, we use doxepin or thioridazin. Another method of treatment is to build tolerance with increasing doses of aspirin, starting at 15 mg per day.
What’s the prognosis? Good after eliminating the causative agent. The reasons for failure to follow an elimination diet are: concomitant stresses, non-compliance with the diet, coexistence of another form of urticaria (delayed oppression).
Fig.5.11. Aspirin hives
Delayed pressure urticaria
Delayed pressure urticaria occurs in about 10% of patients with chronic urticaria, usually after the age of 40. More common in men than in women (exceptionally in young men). Then it has an atypical course, hence it is difficult to recognize. This variety has never been described in children. The etiology of the disease has not been fully elucidated.
symptoms
There are two types of eruptions. Some may mask the presence of the other. First the type (common) has the characteristics of chronic urticaria. In others (rare) hives appear a few hours after pressure (tight garments, work tools, carrying heavy objects). Eruptions persist for 1-3 days. The pain that accompanies them is caused by deep swelling involving the interfascial connective tissue. Additionally, there may be an increase in body temperature and joint pain. Symptoms generally do not depend on the number and severity of urticarial wheals.
Diagnostics
Sometimes leukocytosis, increased ESR, increase in serum histamine. Dermographometers are used to objectively measure sensitivity to pressure. The painful eruption should occur at least 6 hours after a 100 g / 1 mm2 pressure on the back for 70 seconds. If you do not have access to the dermograph, you can use a simple method of sitting on a hard block. The occurrence of the reaction and the degree of its severity depend on the duration of the test.
Treatment
After the diagnosis of delayed pressure urticaria has been established by a specialist dermatologist or allergist, patients can be treated by a general practitioner. Antihistamines only control chronic urticaria eruptions. On the other hand, painful eruptions respond to glucocorticosteroids – they should be administered periodically in severe cases. In some patients, an elimination diet has proved successful.
What’s the prognosis? It is good if you can avoid pressure with hard objects. Some blue-collar workers are forced to change the nature of their work.
Induced urticaria (Fig. 5.12 and 5.13)
Induced urticaria is the most common type of physical urticaria. According to various sources, it is found in 9-87% of patients with chronic urticaria. Onset usually after the age of 25, slightly more common in women. Rarely in young children. It may coexist with other types of urticaria, most often with cholinergic urticaria.
The reasons
The etiology has not been fully elucidated. Mental tension or stress plays a big role in exacerbations.
symptoms
In the course of induced urticaria, symptoms in the form of linear urticarial eruptions appear immediately after scratching with a fingernail or a sharp-edged object. The pruritus that occurs initially causes the sick to scratch. The changes last a dozen or so minutes on average.
The lesions are localized na torso and limbs. A rarer localization is the skin of the eyelids. Swelling of the genital tract and perineum in women has been reported.
Treatment
The patient is administered antihistamines of the second generation – in the case of mild urticaria. Combined antihistamine treatment with drugs acting on both H1 (promethazine) and H2 receptors (cimetidine, ranitidine) in more severe cases. Cimetidine at 200 mg / tabl. in divided doses: one or two tablets until symptoms disappear. Ketotifen is most effective in some patients.
Fig.5.12. Induced urticaria – linear hives on the body.
Fig. 5.13 Urticaria caused by an atopic patient, visible dermographism.
Hives from cold
Cold urticaria occurs in 2-9% of patients with chronic urticaria. It is the only physical urticaria that occurs in children. The family variety is very rare and is characterized by a severe course. The origin of the ailments has not been fully elucidated. There is no specific temperature that will trigger the sowing of hives. Symptoms occur as a result of the skin becoming cold.
symptoms
Clinical symptoms are urticaria wheals or Quincke’s edema in places exposed to cooling. The onset of the disease can be sudden and the course chronic. Winter is difficult for patients, during cold or windy days sowing causes them to leave the house or, for example, to ride a motorcycle.
In summer, the provoking factor is cold water in natural reservoirs or swimming pools. Sudden immersion or jumping into water can cause anaphylactoid shock due to the release of large amounts of histamine. The patient may then become unconscious and drown without immediate help. Quincke’s swellings on the mucous membranes of the mouth, tongue or throat while eating ice cream also occur. Exposure to the cold of a large area of the body in addition to the spread of hives may cause malaise, weakness, vomiting or diarrhea.
Diagnostics
The following are performed: Helicobacter pylori in some patients, IgG and IgM autoantibody complexes, but their pathogenetic role has not been proven. The diagnosis is based on an interview and a positive test with an ice cube placed on the forearm for 10-15 minutes. The occurrence of a blister confirms cold hives. Note: A negative result does not preclude the diagnosis. An additional test involves immersing the forearm in water at 20 degrees Celsius for 10 minutes. The changes disappear 30-60 minutes after the patient is placed in warmth, and diagnostic cooling can also be caused by ethyl chloride.
Treatment
The primary care physician may perform diagnostic tests and start treatment with cyproheptidine (Egis, Peritol, Nuran, Periactin) in doses of 12-24 mg per day. During winter, patients require specialist treatment, also in a hospital setting. Other methods of discussed effectiveness are penicillin 1 million units daily for 10 days, montelukast (Singulair), UV irradiation from 0,02 to 0,4 J / cm2.
Cholinergic urticaria (Fig. 5.14)
Cholinergic urticaria is most common in men aged 15–25. In children under 2 years of age, it is practically unheard of. Patients with cholinergic urticaria constitute 2 to 4% of people with chronic urticaria.
The reasons
The factors provoking the sowing of urticarial wheals are:
- physical effort,
- emotions (75% of respondents),
- hot foods (rarely),
- hot baths.
symptoms
There are hives that do not exceed 3-5 mm in diameter. Sometimes headache, lacrimation, drooling and diarrhea are associated with exanthema. The severity of changes in winter was also reported. The lesions are mainly located on the lateral surfaces of the fingers and the upper part of the torso.
Treatment
GPs can provide care and therapy. Antihistamines are the treatment of choice. Sometimes psychotropic agents (e.g. thioridazin 75 mg daily) or sedatives are very effective. Zaditen (ketotifen) 2 mg 2 times a day are also effective. Danazol is recommended in severe cases.
Light urticaria
Light urticaria is a variety that is very rare in Poland; frequent in the Mediterranean. Over 60% of patients have positive light tests after exposure to UV rays in the range of 350-400 nm. A significant percentage of patients have a positive atopic history. The disease is chronic.
symptoms
Efflorescence appears in the exposed areas several minutes after sun exposure. The localization of the lesions is the auricles, cleavage and shoulders. They are accompanied by severe itching, burning, and extreme pain. Eruptions are short-lived (important diagnostic criterion). Hence, the diagnosis is made mainly on the basis of an interview and completed with light tests.
Light urticaria should be differentiated from:
- multiform light rash,
- erosions,
- vesicular eruptions.
Treatment
After the diagnosis is made by a specialist, pharmacological treatment may be carried out by the general practitioner. Second generation antihistamines are effective. In specialized treatment, UVA and UVB irradiation is used.
Figure 5.14. Cholinergic urticaria. Spreading numerous, tiny hives after exercise.
Allergic and anaphylactoid contact urticaria
It is characterized by the disease zmassive increase in frequency due to widespread use of protective gloves by medical personnel.
A wide variety of substances can cause contact urticaria. These are both haptens and proteins (vegetables, fruits). Other substances are:
- silk,
- wool,
- fur coats,
- acrylates,
- formalin,
- tire.
Latex (a component of rubber) present in rubber products is a contact, inhalation and airborne allergen. Of the drugs, urticaria is triggered by: streptomycin, gentamicin, neomycin, cephalosporins, penicillin, aspirin, menthol.
symptoms
Contact urticaria has three different forms:
1.emergence limited to the point of contact only,
2.excessive reaction at the site of contact and generalized spreading of urticarial wheals,
3. skin lesions and general reaction, eg hay fever, conjunctivitis, asthma, anaphylactic shock.
The basis of treatment is prophylaxis consisting in avoiding harmful substances and the use of protective creams. Usually, antihistamines are effective.
Vascular urticaria
Hives last for more than two days. They don’t usually itch. This form of urticaria may precede or coincide with serious systemic diseases such as systemic lupus erythematosus or cancer. The lesions are scattered and have any location.
Hist.: Neutrophil infiltrates in vessel walls and perivascular space. Present deposits of fibrinogen, immunoglobulins IgA, IgG, IgM.
In the diagnosis of ESR, the concentration of CRP is increased, and the level of complement is lowered. Vascular urticaria should be differentiated from other types of urticaria.
Treatment
When vascular urticaria is suspected, it is the primary care physician’s responsibility to refer the patient to a specialist. It is a serious mistake to overlook vascular urticaria. The prognosis of the disease depends on the underlying disease.
Hydrogenous urticaria
Hydro-urticaria is a relatively rare variety. Symptoms only appear after contact with water, usually regardless of its temperature. The nature of the changes is identical to that in spontaneous urticaria. In some patients, the severity of changes is greater as a result of contact with hypertonic fluids than with hypotonic fluids.
Vibratory urticaria
Symptoms of vibrational urticaria are edema and erythema. Occasionally, there is a headache as a reaction to vibration, after a run, after rubbing violently with a towel. A medical history is helpful in the diagnosis, and specialist examinations are carried out with the use of laboratory shakers.
Urticaria from exercise
The spread of urticarial wheals is accompanied by bronchospasm and a drop in blood pressure. Some people with exercise urticaria do not develop symptoms until they eat certain foods and then exercise.
What is angioedema?
Angioedema (Quincke’s edema) is a type of allergic reaction similar to urticaria but with a much deeper location. In most patients, it occurs as a swelling of the subcutaneous tissue. The swelling is usually painful and diffuse – without clear boundaries. The most common location is the face: eyelids, lips. However, it can affect any part of the body, as well as the digestive, respiratory and urinary systems.
Edema changes may persist for 1-3 days. Swelling is not accompanied by itching; disappears without leaving a trace. If the condition recurs, it often affects the same area of the body. Therefore, over time, the skin in this area may stretch and lose its elasticity (the so-called secondary flaccid skin).
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Types of angioedema
Hives from heat
Heat urticaria is a hives reaction that occurs when a specific body surface is heated to more than 40 degrees Celsius for at least 5 minutes. Quincke’s angioedema. The ailment usually occurs after the age of 15; women get sick more often. The ailment may be the only symptom or coexist with hives.
Cause
The etiology of the disease has not been fully elucidated; in some cases it is a type I reaction. Common triggers include:
- bee stings,
- wasp sting,
- drugs (angiotensin converting enzyme inhibitors),
- vaccinations,
- sometimes food allergens (eggs, nuts, seafood).
symptoms
They occur in the course of the disease oclinks of the subcutaneous, submucosa or deep layers of the dermis occur in various parts of the body. Especially in the area of loose connective tissue, eye sockets, labia, tongue, auricles, labia, scrotum, hands and feet. Swellings distort the area in which they occur. They do not itch or cause discomfort.
In turn, the swelling of the larynx and pharynx directly impedes breathing; in extreme cases it can be fatal. A slight swelling of the larynx causes hoarseness and makes swallowing difficult. On average, the changes last from 8 to 72 hours.
Diagnostics
The diagnostics includes elevated levels of congenital, acquired and drug-induced bradykinin, as well as C1-INH deficiency in familial or acquired angioedema with C1-INH deficiency. Heat urticaria should be differentiated from other types of angioedema.
In familial hereditary edema, there are intestinal symptoms, but there are no hives. Measure C1-INH at all times. Rose, Melkersson-Rosenthal syndrome should be considered in the differentiation of edema of the lips and face. But: In acute pharyngeal and laryngeal edema, the patient’s respiratory tract should be kept open. Pharmacological treatment depends on the area of the edema, its severity and cause. In acute cases, steroids and second-generation antihistamines are useful.
Congenital angioedema
Congenital angioedema is a familial form of C1-INH deficiency and frequent gastrointestinal involvement. It occurs in about 1% of patients with angioedema. The first symptoms appear in childhood; more often in the female sex.
The reasons
Disease inheritance is autosomal dominant. The C1-INH defect, its decrease by 50%, causes the disclosure of clinical changes. Other causes are injuries, surgery, dental procedures, viral infections, and stress are common triggers.
symptoms
In hereditary angioedema, there are prodromal symptoms such as:
- headache
- gastrointestinal complaints (temporary obstruction, pain).
Then painful, non-itchy swellings in any location that last 1-2 hours join. Swelling of the upper respiratory tract is a serious threat. There are no nettle blisters in the disease.
Diagnosis
Diagnostics reveal a decreased level of the complement C4 component, a decrease in C85-INH in 1%, normal in 15% of patients, but with reduced activity. Intestinal X-ray shows segmental swelling of the intestinal wall. Diagnostics should rule out other forms of angioedema.
Treatment
C1-INH 1000-2000 IU concentrate is the treatment of choice in the period of acute edema. Symptoms disappear within hours. In addition, standard anti-shock and antiallergic drugs are being implemented: adrenaline, steroids, antihistamines (their effectiveness is discussed).
Moreover, it is important emergency prophylaxis. 30 minutes before the planned surgery in the area of the head and neck, 500-1000 IU C1-INH, danazol or epsilon-aminocaproic acid should be administered (the last two act slower).
Chronic prophylaxis. Anabolic androgens that stimulate the synthesis of C1-INH in the liver and increase the level of the C4 component. Danazol 50-600 mg daily or stanozolol 2-6 mg daily is recommended. After the symptoms have disappeared, it is advisable to gradually reduce the dose to the lowest effective dose. Antifibrinolytic drugs (epsilon-aminocaproic acid or tranxamic acid) are rated as less effective.
Acquired angioedema type I
These are zsecondary edema changes in the course of neoplasms (type B lymphomas, multiple myeloma, chronic lymphocytic leukemia) or systemic lupus erythematosus. Immune complexes are formed with the activation of the C1 component and the consumption of C1-INH. Treatment of this ailment depends on the underlying disease.
Anaphylactic reaction
The anaphylactic reaction is generalized, immediate IgE-mediated response. The release of a large number of mediators causes various degrees of severe symptoms on the skin, in the digestive, respiratory and circulatory systems.
The triggering factors are:
- contrast agents,
- preservatives,
- food dyes,
- insect venoms,
- aeroalergeny,
- physical factors (cold, heat, light, intense exercise),
- contact urticaria (latex),
- systemic mastocytosis,
- associated action of the above-mentioned factors (e.g., food factor and exercise).
Clinical symptoms
Classification of anaphylactic reactions by severity:
1. Skin: tingling of hands, soles, nose, paroxysmal erythema, urticaria, angioedema, pruritus.
2. Leather: as above;
a. digestive system: nausea, cramps;
b. respiratory system: runny nose, stuffy .., hoarseness;
c. cardiovascular system: tachycardia (? ˘> 20 / min), drop in systolic blood pressure (? ˘> 20 mmHg, arrhythmia).
3. Leather: as above;
a. digestive system: vomiting, diarrhea;
b. respiratory system: laryngeal edema, bronchospasm, cyanosis;
c. circulatory system: shock.
4. Leather: as above;
a. digestive system: vomiting, diarrhea;
b. respiratory system: respiratory failure;
c. circulatory system: cardiac arrest.
It is worth mentioning that the anaphylactoid reaction is clinically identical, but without the involvement of the type I allergic mechanism. Treatment is implemented according to the standard of anti-shock management in a given country.
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Source: Dermatology Doctor’s Guide, Czelej Publishing House