Urticaria

  • Urticaria is derived from Latin word “Urtica” meaning stinging nettle.
  • It is a cutaneous reaction pattern consisting of transient, dermal swellings in form of wheals or angioedema.
  • Individual wheals are pruritic, pink or pale swellings of superficial dermis that have red flare around them and usually subside within 24 hours.

Pruritus, Pale pink well defined swellings (Hives or wheals) Spreads with scratching and coalesce to form large lesions.

  • Course of Lesions: Lesions last 90 minutes to 24 hours

Angioedema, Swelling in laryngeal mucosa

Exogenous (Allergens and Pseudoallergens)

  • Inhalants: pollens, house dust, fungi, dander.
  • Ingestants: fish, egg, brinjal , soy, milk, chocolate, nuts, (pseudoallergens - food additives, dyes, preservatives, flavors).
  • Drugs : NSAIDs, Polymyxin, Vancomycin, Morphine, codeine, Penicillins, Cephalosporins
  • Food likely to cause urticarial: Nuts, fish, chocolates, spices [Act through type I hypersensitivity (IgE mediated)]
  • Food additives such as sodium benzoate, salicylates
  • Act by pseudoallergic mechanism, direct mast cell activators

Endogenous

  • Infections: Gastrointestinal, respiratory, urinary tract infections, Bacterial, protozoal, helminthic, viral (CMV, EBV, HSV)
  • Systemic diseases: Hashimoto’s thyroiditis, Systemic lupus erythematosus, Chronic active hepatitis, Malignancies

Avoid triggering factors

Thyroid disease, Atopic disorders, Vitiligo, Pernicious anemia, Rheumatoid arthritis

How is it diagnosed?

Investigations
  • Hb, TLC/DLC
  • Urine analysis
  • Stool analysis
  • ESR
  • Skin biopsy if lesion present >24 hrs, consider urticarial vasculitis
  • Liver Function Tests
  • TSH / anti TPO
  • ANA
  • IgE levels
  • Autologous serum /plasma skin test
  • Provocation tests for physical urticaria

Dermographism Stroking of skin by blunt object

Delayed pressure urticaria Locally applied weight for 20 min.

Cold urticaria Cold contact (ice cube for 20 min.)

Cholinergic urticaria Physical exercise/hot bath

Aquagenic urticaria Contact with water of any temperature

Exercise anaphylaxis Supervised exercise (shortly after meal)

Solar urticaria Phototesting

 

How is it treated?

  • First use second generation antihistamines in baseline dose.
  • Second step in non responsive patients is to increase the dose by four folds.
  • Third step in antihistamine refractory patients is to use omalizumab, cyclosporine and addition of monteleukast.
  • Fourth step is Dapsone, Colchicine, HCQs, Ranitidine, Methotrexate, Azathioprine.
  • Oral corticosteroids (short courses for 10 days) are useful in
  • Acute severe exacerbations of chronic urticaria
  • Severe angioedema
  • Delayed pressure urticaria
  • Urticarial vasculitis

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