URTICARIA

PresenterAimi Haniza Zainal

Glendy

Advisordr. Nasriyani Zainal

Supervisordr. Safruddin Amin, Sp.KK (K), MARS

INTRODUCTION

URTICARIA

vascular reaction in the skin local edema which rapidly arise & disappear slowly pale and red rises on the skin surface its surroundings can be surrounded by halo.

Acute

If the attack lasts < 6 weeks, or last for 4 weeks but arise every day. More common in young people, generally men more often than women. Most causes : adverse effects of food or due of viral illness.

Chronic

Duration of > 6 weeks Common in middle-aged women Most causes : idiopathic urticaria, or autoimmunity

Predisposing agent

Age

Race

Hygiene

Sex

Hereditary

Environment

EPIDEMIOLOGY

Found 40% of urticaria only, 49% urticaria

together with angioedema and 11% of

angioedema alone. The lifetime occurence of urticaria in the

general population ranges from 1% to 5%.

ETIOLOGY

Medications Food Insect Bites Inhalants

Penicillin drug

Insect wasp

Physical trauma cold,heat, pressure

and stressInfectionSystemic disease

Dermagraphism

Cold urticaria

PATHOGENESIS

(A) Non- immunologic factor

The chemical mediator release

Physical Factors(heat, cold, trauma,light)

Cholinergic effects

Mast cell Basofil

Mediator release(histamine, SRSA,

serotonin, quinine, PEG, PAF)

Vasodilatation↑ capiler

permeability

AlcoholEmotion

Fever

Urticaria

(B) Immunologic factor

Type 1 reaction (IgE)

Type IV reaction (contact)

complement activation: a) Type II reactionb) Type III reactionc) Genetic factor (C1

esterase inhibitor deficiency)

Mast cell Basofil

Mediator release(histamine, SRSA,

serotonin, quinine, PEG, PAF)

Vasodilatation↑ capiler

permeability

Urticaria

CLINICAL FEATURES

Urticaria looks like red skin raised above skin , on any part of the body

Itchy, painful, and hot or burning sensation

Can be in form of papular , lentikular, numular until plaques

• When it extends into the dermis and / subcutaneous and submucosal layer, it is called ‘angioedema’.

•Individual lesions of urticaria arise suddenly, rarely persistent longer than 24-48 hours, and may recur for indefinite period

PICTURES

CLASSIFICATION

Type of urticaria Example1) Ordinary urticaria - Acute & chronic urticaria

2) Physical urticaria - Adrenergic urticaria

- Cholinergic urticaria

- Aquagenic urticaria

- Cold urticaria

- Delayed pressure urticaria- Dermographism- Exercise-induced anaphylaxis- Localized heat urticaria- Solar urticaria- Vibratory angioedema

Type of urticaria Example3) Contact urticaria - Induced by biologic

or chemical skin contact

4) Urticarial vasculitis - Defined by vasculitis as shown by skin biopsy specimen

5) Angioedema without wheals

- Can be caused by idiopathic

Physical Examination

Dermagraphism : Stroke the armIce (ice cube test) or warm water if it is

suspected allergy to a certain temperatureSolar : perform photo paste test.Cholinergic : Intradermal mecholyl

injection can be used to diagnose the cholinergic urticaria

DIAGNOSIS

Allergen testing

1) Skin tests (prick test).

2) Radioallergosorbent tests (RAST) for

hipersensitivity type 1 reaction.

3) Oral challenge testing for food and food

additives.

4) To know the existence of vasoactive factors such as histamine-releasing autoantibodies, intradermal injection test using serum of patients themselves (autologous serum skin test-ASST) can be used.

1) CBC with differential, erythrocyte sedimentation rate (ESR) and urine routine.

Laboratory tests

2) Examination on complement, autoantibodies, elektrofloresis serum, kidney function, liver function and urinalysis

3) Examination of complement C1 inhibitor and C4

DIFFERENTIAL DIAGNOSE

Purpura anaphyla

toid

Erythema

Multiforme

Pityriasis rosea

Purpura anaphylatoid

Lesion : begins as erythematous macular or urticarial lesions, progressing to blanching papules, and later, to palpable purpura.

Pityriasis rosea

• The rash starts with a single large patch called a herald patch.• After several days, more skin rashes will appear on the chest, back, arms, and legs.

Erythema multiforme

• Lesion can be in form of macules, papules or urticaria.• First, spread commonly at lower extremities, palms and backs.

The most ideal treatment is to treat the cause or if possible avoid the cause of the suspect.

If not possible at least try to reduce the causes of these, at least do not use and do not contact with the cause

TREATMENT

1st line treatment

Non-or low-sedating H1 antihistamines

If little or no response

Increase above licensed doseAdd sedating H1 antihistamine at night

If little or no response

Add H2 antagonist

Class Examples Daily adult dose

Classic (sedating) Chlorpheniramine 4 mg tid (up to 12

mg at night)

  Hydroxyzine 10–25 mg tid (up to

75 mg at night)

  Diphenhydramine 10–25 mg at night

  Doxepin 10–50 mg at night

Second-generation Acrivastine 8 mg tid

  Cetirizine 10 mg once daily

  Loratadine 10 mg once daily

  Mizolastine 10 mg once daily

Class Examples Daily adult dose

Newer second-

generation

Desloratadine 5 mg once daily

  Fexofenadine 180 mg once daily

  Levocetirizine 5 mg once daily

H2 antagonists Cimetidine 400 mg bid

Ranitidine 150 mg bid

2nd line treatment

Systemic corticosteroids

Epinehrine

Others(determined by history and

investigations)

Combination therapies (e.g including doxepin)

2nd line treatment

Generic name Drug class Dose

Prednisone Corticosteroid 0.5 mg/kg qd

Epinephrine Sympathomimetic 300–500 mg

Montelukast Leukotriene receptor

antagonist

10 mg qd

Thyroxine Thyroid hormone 50–150 mg qd

Nifedipine Calcium antagonist 10–40 mg

modified-release qd

Colchicine Neutrophil inhibitor 0.6–1.8 mg qd

Sulfasalazine Aminosalicylates 2–4 g qd

3rd line treatment

Immunotherapy• No response to 1st & 2nd line• Example : Cyclosporine 3-5 mg/kg/day, tacrolimus, methotrexate, cyclophosphamide, mycophenolate mofetil dan intravenous Ig.

Acute urticaria better prognosis because the causes can be resolved quickly.

Chronic urticaria is more difficult to overcome because the cause is difficult to find

PROGNOSIS

Urticaria also called ‘nettle-rash’ or ‘hives’ simply means itching with rash.

It usually caused by an allergic reaction, appear as redness with little edema firmly bounded arising quickly after triggered by factors of precipitation and slowly disappear.

CONCLUSION

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