Urticaria

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Pathophysiology

Allergic urticaria on the back

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. mens ski suit

Allergic urticaria on the skin induced by an antibiotic one piece ski suits

Urticaria are 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 non-allergic reaction, differing in the eliciting mechanism of histamine release. boxing shorts

Allergic urticaria on the arm

Allergic urticaria 

Histamine and other pro-inflammatory substances are released from mast cells in the skin and tissues in response to the binding of allergen-bound IgE antibodies to high affinity cell surface receptors. Basophils and other inflammatory cells are also seen to release histamine and other mediators, and are thought to play an important role, especially in chronic urticarial diseases.

Autoimmune urticaria 

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

Infectious 

Hive-like rashes commonly accompany viral illnesses, such as the common cold. They usually appear 35 days after the cold has started, and may even appear a few days after the cold has resolved.

Non-allergic 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.

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 scromboid is reported not to include wheals.

Stress and chronic idiopathic urticaria 

Chronic idiopathic urticaria has been anecdotally linked to stress since the 1940s. There is a large body of evidence demonstrating an association between this condition and both poor emotional well-being and reduced health related quality of life. More recent research has investigated hypotheses about stress as a causal factor in triggering the condition. Evidence has been found for a link between stressful life events (e.g. bereavement, divorce etc...) and preliminary evidence has been reported for a link between posttraumatic stress and chronic idiopathic urticaria. Less is known about the individual experiences and characteristics of people who develop chronic idiopathic urticaria following stress. Research into these factors in the relationship between stress and chronic idiopathic urticaria is ongoing by a number of researchers, including an online project currently being undertaken by researchers at the University of Plymouth.

Differential diagnosis

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/oil dissolving detergent and cool water and rubbing ointments.

Types

Acute urticaria usually show up a few minutes after contact with the allergen and can last a few hours to several weeks. Food allergic reactions often fit in this category. 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. It is uncommon for patients to have more than 2 true food allergies. A less common cause is exposure to certain bacteria, such as streptococcus or possibly Helicobacter pylori. In these cases, the hives may be exacerbated by other factors, such as those listed under Physical Urticarias below.

Chronic urticaria refers to hives that persists for 6 weeks or more. There are no visual differences between acute and chronic urticaria. Some of the more severe chronic cases have lasted more than 20 years. A survey indicated that chronic urticaria lasted a year or more in more than 50% of sufferers and 20 years or more in 20% of them. Of course this does mean that in almost half the people it clears up within a year and in 80% it clears up within 20 years or less.

Drug-induced urticaria has been known to result in severe cardiorespiratory failure. The anti-diabetic sulphonylurea glimepiride (trade name Amaryl), in particular, has been documented to induce allergic reactions manifesting as urticaria. Other cases include dextroamphetamine, aspirin, penicillin, clotrimazole, sulfonamides and anticonvulsants.

Physical urticarias are often categorized into the following.

Aquagenic: Reaction to water (exceedingly rare)

Cholinergic: Reaction to body heat, such as when exercising or after a hot shower

Cold (Chronic cold urticaria): Reaction to cold, such as ice, cold air or water - worse with sudden change in temperature

Delayed Pressure: Reaction to standing for long periods, bra-straps, elastic bands on undergarments, belts

Dermatographic: Reaction when skin is scratched (very common)

Heat: Reaction to hot food or objects (rare)

Solar: Reaction to direct sunlight (rare, though more common in those with fair skin)

Vibration: Reaction to vibration (rare)

Adrenergic: Reaction to adrenaline / noradrenaline (extremely rare)

Related conditions

Angioedema is similar to urticaria, but in angioedema, the swelling occurs in a lower layer of the dermis than it does in urticaria, as well as in the subcutis. This swelling can occur around the mouth, in the throat, in the abdomen, or in other locations. Urticaria and angioedema sometimes occur together in response to an allergen and is a concern in severe cases as angioedema of the throat can be fatal.

Urticaria can be a complication and symptom of a parasitic infection as Fascioliasis (Fasciola Hepatica)and Ascariasis (Ascaris Lumbricoides).[citation needed]

Management

Chronic urticaria can be difficult to treat. There are no guaranteed treatments or means of controlling attacks, and some sub-populations 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 since 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 there are several different forms of urticaria and people often exhibit more than one type. Also, since symptoms are often idiopathic (unknown reason) there might not be any clear trigger. If one's triggers can be identified then outbreaks can often be managed by limiting one's exposure to these situations.

Histamine antagonists

Drug treatment is typically in the form of antihistamines such as diphenhydramine, hydroxyzine, cetirizine and other H1 receptor antagonists. These are taken on a regular basis to protective effect, lessening or halting attacks. While the disease may be physiological in origin, psychological treatments such as stress management can sometimes lessen severity and occurrence. Additionally, methods similar to psychological pain management can be used to shift focus away from the discomfort and itchiness during an attack.

The H2-receptor antagonists such as cimetidine and ranitidine may help control symptoms either prophylactically or by lessening symptoms during an attack. When taken in combination with a H1 antagonist it has been shown to have a synergistic effect which is more effective than either treatment alone.[citation needed] The use of ranitidine (or other H2 antagonist) for urticaria is considered an off-label use, since these drugs are primarily used for the treatment of peptic ulcer disease and gastroesophageal reflux disease.

Other

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 corticosteroids and as such is not a recommended long-term treatment option.

As of 2008 an Australian company is performing clinical trials with an analogue of alpha-melanocyte-stimulating hormone called afamelanotide (formerly CUV1647) for the treatment of solar urticaria, a type of urticaria that develops in response to exposure to specific wavelengths of light.

Dietary

Children with intermittent or recurrent urticaria-angiodema were fed 7 food-additives: tartrazine (E102), sunset yellow (E110), erythrosine (E127), annatto (E160b), sodium benzoate (E211), acetyl-salicylic acid (ASA), and aspartame. Reactions to the food additives were common: E102 = 50%, E110 = 64%, E127 = 35%, E160b = 60%, E211: 57%; ASA = 12%, aspartame = 48%. The authors suggest that food additive intolerance is frequent in children with recurrent or intermittent urticaria-angiodema, and that aspartame may contribute directly to urticaria-angiodema in childhood.

See also

Wheals

Acute urticaria

Chronic urticaria

Anti-itch drug

Chronic cold urticaria

Urticaria pigmentosa

Cholinergic urticaria

Maculopapular rash

kallikrein

List of cutaneous conditions

Virus identified as likely cause[citation needed]  

References

^ "urticaria" The Oxford English Dictionary. 2nd ed. 1989. OED Online. Oxford University Press. 2 May 2009.

^ http://dermnetnz.org/reactions/scombroid.html

^ Mitchell, J., Curran, C., and Myers, R. (1947) Some Psychosomatic Aspects of Allergic Diseases. Psychosomatic Medicine: 9(3), 184-191. .

^ Uguz, F., Engin, B., and Yilmaz, E. (2008a) Axis I and Axis II diagnoses in patients with chronic idiopathic urticaria. Journal of Psychosomatic Research, 64: 225-229. .

^ Engin, B., Uguz, F., Yilmaz, E., zdemir, M., and Mevlitoglu, I. (2007) The levels of depression, anxiety and quality of life in patients with chronic idiopathic urticaria. Journal of the European Academy of Dermatology and Venereology, 22(1): 36-40. .

^ Yang, H., Sun, C., Wu, Y., and Wang, J. (2005) Stress, insomnia, and chronic idiopathic urticaria: a case-control study. Journal of the Formos Medical Association, 104(4): 254-263. .

^ Chung, M., Symons, C., Gilliam, J., and Kaminski, E. (2008b) The relationship between post-traumatic stress resulting from past traumas, coping strategies and chronic idiopathic urticaria (CIU). Poster presented at the British Psychological Society Annual Conference.

^ Life Events and Chronic Idiopathic Urticaria research project, University of Plymouth, England. .

^

^ Tebbe B, Geilen CC, Schulzke JD, Bojarski C, Radenhausen M, Orfanos CE (April 1996). "Helicobacter pylori infection and chronic urticaria". J. Am. Acad. Dermatol. 34 (4): 6856. doi:10.1016/S0190-9622(96)80086-7. PMID 8601663. http://linkinghub.elsevier.com/retrieve/pii/S0190-9622(96)80086-7. 

^ Champion RH, Roberts SO, Carpenter RG, Roger JH (1969). "Urticaria and angio-oedema. A review of 554 patients". Br. J. Dermatol. 81 (8): 58897. doi:10.1111/j.1365-2133.1969.tb16041.x. PMID 5801331. 

^ "Prescribing Information Dexedrine". GlaxoSmithKline. June 2006. http://dailymed.nlm.nih.gov/dailymed/fdaDrugXsl.cfm?id=1215&type=display. 

^ angioedema at Dorland's Medical Dictionary

^ "Hives (Urticaria and Angioedema)". 2006-03-01. http://www.webmd.com/allergies/guide/hives-urticaria-angioedema. Retrieved 2007-08-24. 

^ Greaves MW, Tan KT (2007). "Chronic Urticaria: Recent Advances". Clin Rev Allergy Immunol 33 (1-2): 134143. doi:10.1007/s12016-007-0038-3. PMID 18094952. 

^ Lee EE, Maibach HI (2001). "Treatment of urticaria. An evidence-based evaluation of antihistamines". Am J Clin Dermatol 2 (1): 2732. doi:10.2165/00128071-200102010-00005. PMID 11702618. 

^ "World Health Organisation assigns CUV1647 generic name" (PDF). Clinuvel. 2008. http://www.clinuvel.com/resources/pdf/asx_announcements/2008/20080617WHOGenericName.pdf. Retrieved 2008-06-17. 

^ McDonald, Kate (2007-04-13). "Tackling skin cancer in organ transplant patients". Australian Life Scientist. http://www.biotechnews.com.au/index.php/id;444900667. Retrieved 2007-12-24. 

^ "Clinuvel gets green light". Biotechnews.com.au (LifeScientist). 2007-06-11. http://www.biotechnews.com.au/index.php/id;1708412693;fp;16;fpid;1. Retrieved 2008-06-13. 

^ Baron, ED; Taylor, CR (2007-03-29). "Urticaria, Solar". WebMD. http://www.emedicine.com/derm/topic448.htm. Retrieved 2007-12-26. 

^ de Martino M, Peruzzi M, Galli L, Lega L, Zammarchi E, Vierucci A (1992). "Food-additive intolerance and its correlation with atopy in children with recurrent or intermittent urticaria-angioedema". Pediatric Allergy and Immunology 3 (1): 3338. doi:10.1111/j.1399-3038.1992.tb00024.x. http://www3.interscience.wiley.com/journal/119332669/abstract. 

External links

Urticaria photo library at Dermnet

v  d  e

Diseases of the skin and appendages by morphology

Growths

Epidermal

wart  callus  seborrheic keratosis  acrochordon  molluscum contagiosum  actinic keratosis  squamous cell carcinoma  basal cell carcinoma  merkel cell carcinoma  nevus sebaceous  trichoepithelioma

Pigmented

Freckles  lentigo  melasma  nevus  melanoma

Dermal and

subcutaneous

epidermal inclusion cyst  hemangioma  dermatofibroma  keloid  lipoma  neurofibroma  xanthoma  Kaposi's sarcoma  infantile digital fibromatosis  granular cell tumor  leiomyoma  lymphangioma circumscriptum  myxoid cyst

Rashes

With

epidermal

involvement

Eczematous

contact dermatitis  atopic dermatitis  seborrheic dermatitis  stasis dermatitis  lichen simplex chronicus  Darier's disease  glucagonoma syndrome  langerhans cell histiocytosis  lichen sclerosus  pemphigus foliaceus  Wiskott-Aldrich syndrome  Zinc deficiency

Scaling

psoriasis  tinea (corporis  cruris  pedis  manuum  faciei)  pityriasis rosea  secondary syphillis  mycosis fungoides  systemic lupus erythematosus  pityriasis rubra pilaris  parapsoriasis  ichthyosis

Blistering

herpes simplex  herpes zoster  varicella  bullous impetigo  acute contact dermatitis  pemphigus vulgaris  bullous pemphigoid  dermatitis herpetiformis  porphyria cutanea tarda  epidermolysis bullosa simplex

Papular

scabies  insect bite reactions  lichen planus  miliaria  keratosis pilaris  lichen spinulosus  transient acantholytic dermatosis  lichen nitidus  pityriasis lichenoides et varioliformis acuta

Pustular

acne vulgaris  acne rosacea  folliculitis  impetigo  candidiasis  gonococcemia  dermatophyte  coccidioidomycosis  subcorneal pustular dermatosis

Hypopigmented

tinea versicolor  vitiligo  pityriasis alba  postinflammatory hyperpigmentation  tuberous sclerosis  idiopathic guttate hypomelanosis  leprosy  hypopigmented mycosis fungoides

Without

epidermal

involvement

Red

Blanchable

Erythema

Generalized

drug eruptions  viral exanthems  toxic erythema  systemic lupus erythematosus

Localized

cellulitis  abscess  boil  erythema nodosum  carcinoid syndrome  fixed drug eruption

Specialized

urticaria  erythema (multiforme  migrans  gyratum repens  annulare centrifugum  ab igne)

Nonblanchable

Purpura

Macular

thrombocytopenic purpura  actinic purpura

Papular

disseminated intravascular coagulation  vasculitis

Indurated

scleroderma/morphea  granuloma annulare  lichen sclerosis et atrophicus  necrobiosis lipoidica

Miscellaneous

disorders

Ulcers

Hair

telogen effluvium  androgenic alopecia  trichotillomania  alopecia areata  systemic lupus erythematosus  tinea capitis  loose anagen syndrome  lichen planopilaris  folliculitis decalvans  acne keloidalis nuchae

Nail

onychomycosis  psoriasis  paronychia  ingrown nail

Mucous

membrane

aphthous stomatitis  oral candidiasis  lichen planus  leukoplakia  pemphigus vulgaris  mucous membrane pemphigoid  cicatricial pemphigoid  herpesvirus  coxsackievirus  syphilis  systemic histoplasmosis  squamous cell carcinoma

v  d  e

Diseases of the skin and subcutaneous tissue (integumentary system) (L, 680-709)

Infections

Bacterial

skin disease

Staphylococcus (Staphylococcal scalded skin syndrome, Impetigo, Boil, Carbuncle)  Strep (Impetigo)  Corynebacterium (Erythrasma)

Viral

skin disease

Wart  Molluscum contagiosum  Erythema infectiosum  Exanthema subitum  Herpes simplex (Herpetic whitlow, Eczema herpeticum)

General

Cellulitis (Paronychia)  Acute lymphadenitis  Pilonidal cyst  Pimple (Pustule)

Bullous

disorders

acantholysis (Pemphigus, Transient acantholytic dermatosis)  Pemphigoid (Bullous, Cicatricial, Gestational)  Dermatitis herpetiformis

Inflammatory

Dermatitis

and eczema

Atopic dermatitis  Seborrhoeic dermatitis (Dandruff, Cradle cap)  Contact dermatitis (Diaper rash, Urushiol-induced contact dermatitis)  Erythroderma  Lichen simplex chronicus/Prurigo nodularis  Itch (Pruritus ani, Pruritus scroti, Pruritus vulvae)  Nummular dermatitis  Dyshidrosis  Pityriasis alba

Papulosquamous

disorders

Psoriasis (Psoriatic arthritis)  Parapsoriasis (Pityriasis lichenoides et varioliformis acuta, Pityriasis lichenoides chronica, Lymphomatoid papulosis)  other pityriasis (Pityriasis rosea, Pityriasis rubra pilaris)  other lichenoid (Lichen planus, Lichen nitidus)

Urticaria

Dermatographic urticaria  Cold urticaria  Cholinergic urticaria  Solar urticaria

Erythema

Erythema multiforme/

drug eruption

Stevens-Johnson syndrome  Toxic epidermal necrolysis  Erythema nodosum   Acute generalized exanthematous pustulosis

Other erythema

Erythema annulare centrifugum  Erythema marginatum  Keratolytic winter erythema  Necrolytic migratory erythema  Erythema toxicum

Radiation-related

disorders

Sunburn  actinic rays (Actinic keratosis, Actinic cheilitis)  Polymorphous light eruption (Acne aestivalis)  Radiodermatitis  Erythema ab igne

Pigmentation/

Dyschromia

hypopigmentation (Albinism, Vitiligo)  hyperpigmentation (Melasma, Freckle, Caf au lait spot, Lentigo/Liver spot, Acanthosis nigricans, Acral acanthotic anomaly)

Other skin

keratosis/hyperkeratosis (Seborrheic keratosis, Callus)  other epidermal thickening (Ichthyosis acquisita, Palmoplantar keratoderma)

skin ulcer (Pyoderma gangrenosum, Bedsore)

Cutaneous Markers of Internal Malignancy (Florid cutaneous papillomatosis, acanthosis nigricans, sign of Leser-Trelat)

atrophic (Lichen sclerosus, Acrodermatitis chronica atrophicans)

necrobiosis (Granuloma annulare, Necrobiosis lipoidica)  other granuloma (Granuloma faciale, Pyogenic granuloma)

cutaneous vasculitis (Livedoid vasculitis, Erythema elevatum diutinum)

Connective

tissues

collagen disease: Keloid

localized connective tissue disorders: Lupus erythematosus (Discoid lupus erythematosus, Subacute cutaneous lupus erythematosus)  Scleroderma/Morphea  Linear scleroderma  Calcinosis cutis  Sclerodactyly  Ainhum

integument, SF, LCT navs: anat/physio, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc

v  d  e

Immune disorders: hypersensitivity and autoimmune diseases

Type I/allergy/atopy

(IgE)

Foreign

Atopic dermatitis  Allergic urticaria  Hay fever  Allergic asthma  Anaphylaxis  Food allergy (Milk, Egg, Peanut, Tree nut, Seafood, Soy, Wheat), Penicillin allergy

Autoimmune

none

Type II/ADCC

(IgM, IgG)

Foreign

Pernicious anemia  Hemolytic disease of the newborn

Autoimmune

Cytotoxic

Autoimmune hemolytic anemia  Idiopathic thrombocytopenic purpura   Bullous pemphigoid   Pemphigus vulgaris  Rheumatic fever  Goodpasture's syndrome

"Type 5"/receptor

Graves' disease  Myasthenia gravis

Type III

(Immune complex)

Foreign

Henoch-Schnlein purpura  Hypersensitivity vasculitis  Reactive arthritis  Rheumatoid arthritis  Farmer's lung  Post-streptococcal glomerulonephritis  Serum sickness  Arthus reaction

Autoimmune

Systemic lupus erythematosus  Subacute bacterial endocarditis

Type IV/cell-mediated

(T-cells)

Foreign

Contact dermatitis  Mantoux test

Autoimmune

Diabetes mellitus type 1  Hashimoto's thyroiditis  Guillainarr syndrome   Multiple sclerosis   Coeliac disease  Giant cell arteritis

GVHD

Transfusion-associated graft versus host disease

Unknown/

multiple

Foreign

Hypersensitivity pneumonitis (Allergic bronchopulmonary aspergillosis)  Transplant rejection  Latex allergy (I+IV)

Autoimmune

Sjgren's syndrome  Autoimmune hepatitis  Autoimmune polyendocrine syndrome (APS1, APS2)  Autoimmune adrenalitis

lymphocyte navs: cells/physio, immunodeficiency/immunoproliferative immunoglobulin/neoplasia, proc

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