diagnosis and treatment of physical urticaria

Physical Urticaria

Theerapan SongnuyDec 7, 2012

Overview

• Definition• Epidemiology• Classification• Diagnosis• Treatment

UrticariaUrticaria : - The appearance of pruritic,erythematous skin elevation which blanch with pressure - Small venules & capillaries dilation in superficial dermis - Collagen fiber swelling Angioedema : - similar pathologic reaction - Involves deep dermis & subcutaneous tissue - Fewer mast cell & sensory nerve ending - More painful or burning sensation than pruritus - Often on face, tongue ,genitalia & extremities

Middleton’s Allergy 7th Edition

Physical Urticaria

• A heterogeneous group of inducible conditions that includes:

- Symptomatic dermographism/urticaria factitia - Cold contact urticaria - Heat contact urticaria - Delayed pressure urticaria - Vibratory urticaria /angioedema - Solar urticarias - Aquagenic urticaria - Contact urticaria - Exercise induced urticaria /anaphylaxis Allergy 2009; 64 (12): 1715-1721

Physical Triggers• Symptomatic dermographism / Urticaria factitia :

mechanical stroking• Cold contact urticaria : skin contact with cold

air/water/solids• Heat contact urticaria : skin contact with hot

air/water/solids• Delayed pressure urticaria: vertical sustained pressure• Vibratory urticaria/angioedema : vibration (e.g. pneumatic

hammer) • Solar urticaria : UV and/or visible light • Aquagenic urticaria : water contact at any temperature• Contact urticaria : contact with an allergic or nonallergic

stimulus• Exercise induced urticaria /anaphylaxis : physical exercise• Cholinergic urticaria : increased core body temperature Allergy 2009; 64 (12): 1715-1721

Epidemiology

• Urticaria - The life-time prevalence of any subtype is 20%

• Physical urticaria - prevalence 20% of chronic urticaria - In children prevalence ranges from 6.2-25.5%

Allergy 2009;64: 1417-1426Ann Allergy 1993:71:205-12Ann Allergy 1992; 69: 61-65

Aim: To study the prevalence, type, clinical data & natural history of physical urticaria includingprognostic factors for remissionMaterial & Methods : - A retrospective study - The Dermatologic Unit, Siriraj Hospital - Jan 2003-Dec 2008 - Patients aged above 18 years - Demographic data, causes of urticaria, associated diseases, physical exammination, lab etc.JEADV 2011 ; 25: 1194-1199.

• Tests to categorize type

- Dermographometer ( pressure at 4900 g/cm2 ) - Delayed-pressure ( sandbags 15 lbs over one shoulder for 15 min) then observe 2-8 hr. later

- Cold urticaria ( Ice-cube test, place ice inside plastic bag on forearm 10 min then observe 15 min later

- Cholinergic ( run until exhausted & sweaty ) then observe within 15 min

- Adrenergic ( ID noradrenalin 3-10 ng in 0.02 ml saline observe erythematous papule & halo ) JEADV 2011 ; 25: 1194-1199.

• Tests to categorize type - Solar urticaria ( photo test with visible light UVA, UVB ) - Others ; CBC, UA, ESR, ANA, cryoglobulin HBsAg, anti-HCV Ab etc.

Remission: non-urticarial wheal for at least 6 months after stop medication & negative test

JEADV 2011 ; 25: 1194-1199

JEADV 2011 ; 25: 1194-1199

• From chronic urticaria: physical urticaria was 7.2%• The most common type is symptomatic dermographism

• Only 13.9% associated with chronic spontaneous urticaria• No multiple types of physical urticaria

• ESR was the most common abnormal labs• The median time after onset before 50% remission - Cholinergic urticaria took the shortest course - Delayed-pressure took the longest period - After 1 y & 5 y from onset of symptom, 13 % & 50% of physical urticaria were free of symptoms

Symptomatic Dermatographism

• Syn : urticaria factitia, dermographic urticaria• The most common subtype of physical urticaria• Has to be differentiated from simple

Dermographism where wealing, but not pruritus, occurs after moderate stroking of the skin

• Develope itching & wealing at a lower force than that required to induce simple dermographism

• Other types of dermographism such as white dermographism (in atopic patients) are unrelated to symptomatic dermographism

Immunol Allergy Clin North Am2004;24:225–246.


• Provocation testing

- A dermographometer : to apply a rubbing stimulus to a subject’s skin using predefined and reproducible pressures

- A calibrated dermographometer is commercially available (HTZ Limited, Vulcan Way, New Addington, Croydon, Surrey, UK)

- It has a spring-loaded smooth steel tip 0.9 mm in diameter. The pressure on the tip can be varied by turning a screw at the top of the instrument.

- The scale settings from 0 to 15 ( tip pressures from 20 to 160

g/mm2 )


Figure 3 Dermatographism. Linear stroking of skin elicits a wheal within several minutes.

The American Journal of Medicine 2008; 121 ( 5) : 379 - 384


• Diagnosis of symptomatic dermographism -the smooth blunt object should be held

perpendicular to and used to apply a light stroking pressure to the skin of the upper back or volar forearm

- The skin at the test site should be unbroken and free of obvious signs of infection

-Three parallel lines (up to 10 cm long) should be made with dermographometer settings equivalent to 20, 36 and 60 g/mm2.



• The positive reaction : showing a wheal response & report pruritus at the site of provocation at 36 g/mm2 (353 kPa) or less

• A wheal response without itch on provocation at 60 g/mm2 (589 kPa) or higher indicates

simple dermographism• The test response should be read 10 min

after testing

J Am Acad Dermatol2008;59:752–757.

Management of Symptomatic Dermatographism

• Diphenhydramine or hydroxyzine 25-50 mg. qid for severe patient

• Non-sedating antihistamine in mildly to moderately severe cases, can be triple the usual dose

Middleton’s Allergy 7TH Edition

Conclusion

• Cyclosporin may be worth trying for antihistamine-resistant DU,

especially in those patient cases characterized by severe itching

. Further studies on a larger scale are expected to be conducted in order to generate stronger levels of clinical evidence.

Cold Urticaria & Related Disorders

• Trigger by a cold stimulus ; wind, liquid holding cold objects• Total body exposure can lead to hypotension ( swimming)• Disease begin in any age group, young adult• “Ice-cube Test” placing a plastic containing ice cube

inside on patient’s forearm for 4 min, then observe 10 min


Cold Urticaria• Positive : a palpable & clearly visible weal & flare reaction with

itchy and/or burning sensation• In a positive test reaction, threshold testing should be performed

• Threshold level may help patients to avoid risky situations and their physician to optimize treatment

• Determining the stimulation time threshold, which is the shortest duration of cold exposure required to induce a positive test reaction

• Temperature thresholds, i.e. the highest temperature sufficient to induce a positive test reaction, can be assessed with TempTest

J Allergy Clin Immunol1986;78:417–423.

Cold-Dependent Syndromes• Idiopathic cold urticaria• Systemic cold urticaria( ice cube test negative) sensitive to

cold air• Cold-induced cholinergic urticaria• Cold-dependent dermographism• Delayed cold urticaria ( edema, pain)• Localized cold urticaria ( previous insect stinging)• Cold reflex urticaria• Associated with abnormal serum protein - cryoglobulinemia - cold agglutinin disease - cryofibrinogenemia - paroxysmal cold hemoglobinuria


Cold Urticaria

• Mediators releasing from mast cell - histamine - PAF - LTE2 - Prostaglandin D2 - TNF-alpha - IL-3


Management of Cold Urticaria

• Avoidance• Cyproheptadine is the drug of choice• Non-sedating H1 antihistamine• For patient where IgE has a role,

monoclonal IgG anti-IgE may be effective


Atopic dermatitis and skin disease High-dose desloratadine decreases wheal

volume and improves cold provocation thresholds compared with standard-dose treatment in patients with acquired cold urticaria

: A randomized, placebo-controlled, crossover study

Frank Siebenhaar, MD, Franziska Degener, MD,Torsten Zuberbier, MD, Peter Martus, PhD,andMarcus Maurer, MD Berlin, Germany

J Allergy Clin Immunol 2009;123:672-9

- Aim: assess the effects of 5 and 20 mg of desloratadine and placebo on cold-induced

urticarial reactions in patients with acquired

cold urticaria (safety & efficacy)

- A prospective, double-blind, randomized, placebo-controlled crossover study


• Materials & Methods - OPD of urticaria specialty clinic of the Allergie-Centrum-

Charite´ of the Charite´-Universita¨tsmedizin, Berlin, Germany

- Patients aged 18 to 75 years with a confirmed diagnosis of Acquired Cold Urticaria , made at least 6 week before

- Signs/symptoms were assessed by using the Acquired Cold Urticaria Severity Index (ACUSI), & triggering stimuli, previous medication use, and concomitant disease


B, Example of thermographic images of the cold-induced wheal response over 20 minutes in a patient with ACU treated with placebo, 5 mg/d and 20 mg/d desloratadine for 7 days


Conclusion

Treatment with desloratadine at doses of 5 and 20 mg daily significantly decreased wheal volume/size , improved CTTs & CSTTs in patients with ACU

Treatment with the higher dose of desloratadine yields higher outcomes in wheal volume and CTTs and CSTTs comparing with standard-dose desloratadine


Solar Urticaria Treated With Intravenous Immunoglobulins

HenriAdamski,MD, Christophe Bedane, MD, Annie Bonnevalle, MD, Pierre Thomas, MD, Jean-Louis Peyron, MD, Bernard Rouchouse, MD, Frederic Cambazard, MD, Michel Jeanmougin, MD,and Manuelle Viguier, MD Rennes, Limoges, Lille, Montpellier, Saint-Etienne, and Paris, France

J Am Acad Dermatol 2011;65:336-40

Solar urticaria treated with intravenous immunoglobulins

• To report the effectiveness of intravenous immunoglobulins (IVIG) in severe solar urticaria ( SU)

• A retrospective multicentric study via the mailing of a questionnaire to the French Photodermatology Units

• Severe SU was defined as having a poor response to antihistamine use and impairment of the quality of life (impact on daily and professional life)

• Collected age, sex, medical history, medications, clinical features, pho-tobiological characteristics, laboratory investiga-tions, and clinical response to IVIG


Table 1 Characteristics of patients before receiving IVIG


Solar Urticaria

- A rare idiopathic photodermatosis- Sun avoidance and antihistamine - Severe solar urticaria needs more modality such as intravenous immunoglonulins- Further trials are needed

Thank You Very Much

diagnosis and treatment of physical urticaria

Documents

chronic urticaria

epidemiology urticaria

dermographic urticaria

physical urticaria prevalence

temperature contact

chronic spontaneous

cold urticaria icecube

skin contact