Urticaria andUrticaria andAngioedemaAngioedema

Dr Amir Hossein SiadatDr Amir Hossein Siadat

DEFINITIONDEFINITION

Urticaria is defined as a skin lesion Urticaria is defined as a skin lesion consisting of a wheal-and-flare consisting of a wheal-and-flare reaction in which Iocalized reaction in which Iocalized intracutaneous edema (wheal) is intracutaneous edema (wheal) is surrounded by an area of redness surrounded by an area of redness (erythema) that is typically pruritic.(erythema) that is typically pruritic.

Individual hives can last from as briefly Individual hives can last from as briefly as 30 minutes to as long as 36 hours.as 30 minutes to as long as 36 hours.

They can be as small as a millimeter They can be as small as a millimeter or 6 to 8 inches in diameter (giant or 6 to 8 inches in diameter (giant urticaria). urticaria).

They blanch with pressure as the They blanch with pressure as the dilated blood vessels are compressed, dilated blood vessels are compressed, which also accounts for the central which also accounts for the central pallor of the wheal.pallor of the wheal.

Photo Images of HivesPhoto Images of Hives

Angioedemas (quinkes edema) affect Angioedemas (quinkes edema) affect deeper dermal ,subcutaneus and sub deeper dermal ,subcutaneus and sub mucosal tissues.mucosal tissues.

They are usually painfull rather than They are usually painfull rather than itchy ,poorly defined and pale or itchy ,poorly defined and pale or normal in colornormal in color

AngioedemaAngioedema

Swelling of lips, face, hands, feet, penis or scrotumSwelling of lips, face, hands, feet, penis or scrotum

Facial swelling most prominent in periorbital areaFacial swelling most prominent in periorbital area

May be accompanied by swelling of the tongue or pharynxMay be accompanied by swelling of the tongue or pharynx

Larynx virtually never involvedLarynx virtually never involved

Urticaria is classified to acute and Urticaria is classified to acute and chronic with a time devision between chronic with a time devision between 6w and 3m.6w and 3m.

When urticaria is present daily or When urticaria is present daily or almost daily for less than 6w it is almost daily for less than 6w it is acute.acute.

CLINICAL CLASSIFICATION OF CLINICAL CLASSIFICATION OF URTICARIA:URTICARIA:

1)ORDINARY URTICARIA (acute or 1)ORDINARY URTICARIA (acute or chronic)chronic)

2)physical and cholinergic2)physical and cholinergic 3)Urticarial vasculitis3)Urticarial vasculitis 4)Contact Urticaria4)Contact Urticaria 5)angioedema 5)angioedema

Up to 50%of patients previously Up to 50%of patients previously diagnosed as chronic idopathic diagnosed as chronic idopathic urticaria have an autoimune bases.urticaria have an autoimune bases.

Acute ordinary urticaria may be due Acute ordinary urticaria may be due to allergy especially in atopics but to allergy especially in atopics but not in chronic.not in chronic.

ASSOCIATIONSASSOCIATIONS 1)an association between chronic ordinary u and 1)an association between chronic ordinary u and

autoimune thyroid diseaseautoimune thyroid disease 2)there is a higher frequency of autoimune 2)there is a higher frequency of autoimune

diseases in patients with autoimune udiseases in patients with autoimune u The older litrature suggest that chronic idiopathic The older litrature suggest that chronic idiopathic

u may be associated with chhronic infection u may be associated with chhronic infection especially dental and candida of the bowel but especially dental and candida of the bowel but now it occures rarely if at allnow it occures rarely if at all

4)it has been proposed that H.PYLORI infection 4)it has been proposed that H.PYLORI infection may play an indirect role in autoimune chronic u may play an indirect role in autoimune chronic u by molecular mimicry in genetically predisposed by molecular mimicry in genetically predisposed individualsindividuals

5)no association with malignancies was found in a 5)no association with malignancies was found in a large studylarge study

PREVALANCE:PREVALANCE:

POINT PREVALANCE=0.1%POINT PREVALANCE=0.1% Cumulative life time prevalance:0.05-Cumulative life time prevalance:0.05-

23.6% in general population but a 23.6% in general population but a range of 1-5% is more realisticrange of 1-5% is more realistic

72% ordinary urticaria,20%physical 72% ordinary urticaria,20%physical and choloinergic,3.4%allergic(exept and choloinergic,3.4%allergic(exept stings and injected drug),2.1% stings and injected drug),2.1% u.vasculitis,0.5% hereditary u.vasculitis,0.5% hereditary angioedemaangioedema

GENETICSGENETICS

Hereditary C1 Estrase defficiency Hereditary C1 Estrase defficiency angioedemaangioedema

Muckle Well SynMuckle Well Syn Familial cold urticariaFamilial cold urticaria

Highly significant linkage of HLA DR4 Highly significant linkage of HLA DR4 and HLA DQ8 in chronic ordinary and HLA DQ8 in chronic ordinary urticaria.urticaria.

Phathophysiology:Phathophysiology:

Urticaria is due to a local increase in Urticaria is due to a local increase in permeability of capillaries of venules.permeability of capillaries of venules.

It is due to activation of cutaneus It is due to activation of cutaneus mast cells that contain many mast cells that contain many mediators predominantly histamin.mediators predominantly histamin.

Pathophysiology of Urticaria

Non-immunologic factors Immunologic factorsChemical histamine liberatorseg. Opiates, polymyxin antibiotics,thiamine

Physical agents, e.g.cold, heat, sunlight

genetic factors

modulating factors

Alternativecomplement

pathway action

Types II and IIIcomplement

activation

Type I IgEmediated

Anaphylatoxins (C3a, C5a)

URTICARIA

Cholinergic

endogenoushormone

vasodilatingfactors

released mediators(particularly histamine)

Small bloodvessel

vasodilation

Clinical features of acute or Clinical features of acute or chronic urticaria:chronic urticaria:

Ithcing erythematous macules Ithcing erythematous macules develop into weals consisting of pale develop into weals consisting of pale to pink edematous raised areas of to pink edematous raised areas of skin often with a surrounding flareskin often with a surrounding flare

It occurs any where (scalp and It occurs any where (scalp and palms),in any number and size, any palms),in any number and size, any shape even bulla.shape even bulla.

Wheals are often very itchy Wheals are often very itchy especially at night and resolve in a especially at night and resolve in a few hour without any residue.few hour without any residue.

Patient always rub not scratch so Patient always rub not scratch so excoriation is absent.excoriation is absent.

Sometimes they bruise like in thigh.Sometimes they bruise like in thigh. Wheals are more prominent at Wheals are more prominent at

evening and premensevening and premens

In 50% of of urticaria: there may be In 50% of of urticaria: there may be angioedema.angioedema.

Angioedema color is like skin ,most Angioedema color is like skin ,most frequently on the face but any other frequently on the face but any other area such as ear ,genitalia,hand and area such as ear ,genitalia,hand and feetfeet

It may last for several days,It may last for several days, It is not always itchy and and may be It is not always itchy and and may be

painfulpainful

Urticaria may be proceeded with vomiting.Urticaria may be proceeded with vomiting. It may be associated with: It may be associated with: malaise malaise loss of concentration loss of concentration feeling hot or coldfeeling hot or cold headache headache vomitingvomiting abdominal pain abdominal pain diarrhoeadiarrhoea arthralgiaarthralgia dizziness dizziness scyncope scyncope And even anaphylaxiesAnd even anaphylaxies

Urticaria in infancy:Urticaria in infancy:

Cows milk allergy is the commonest Cows milk allergy is the commonest etiology of urticaria in infants under etiology of urticaria in infants under 6m6m

In infants there may be less itching In infants there may be less itching and more tendency to purpuric and more tendency to purpuric wheals,wheals,

Bizzarly shaped wheals are more Bizzarly shaped wheals are more commoncommon

ACUTE URTICARIA:ACUTE URTICARIA:

1) Idiopathic:1) Idiopathic:

Most common type: >50% of casesMost common type: >50% of cases

Sometimes is observed following Sometimes is observed following URTIURTI

2)ALLERGIC:2)ALLERGIC: Is due to interaction of allergen with Is due to interaction of allergen with

IgE bound to mast cellsIgE bound to mast cells more common in atopics,more common in atopics, Although it is unusual to find an Although it is unusual to find an

allergic cause, any drug ,food, allergic cause, any drug ,food, inhalatant and foreign inhalatant and foreign substance( implants, contactants and substance( implants, contactants and injection should be considered).injection should be considered).

In an IgE mediated reaction there In an IgE mediated reaction there have been a previous exposure and have been a previous exposure and the reaction will occur in minutes the reaction will occur in minutes (less than 60 min)(less than 60 min)

Acute urticaria from drug is common Acute urticaria from drug is common and usually occur within 36h (it is and usually occur within 36h (it is unusual for a drug that is contiuously unusual for a drug that is contiuously taken for monthstaken for months

Antibiotics especially penicilin and Antibiotics especially penicilin and cephalosporin are common causes.cephalosporin are common causes.

Risk factors:Risk factors: previous exposure previous exposure reaction to a drug or chemically related reaction to a drug or chemically related

drugdrug intermittant and multiple drug therapy ,intermittant and multiple drug therapy , familial predispositionfamilial predisposition

Food: common within minutes but Food: common within minutes but occasionally many hours after due to occasionally many hours after due to slow absorption or metabolismslow absorption or metabolism

Common food: Shrimp, Crab, Fish, Common food: Shrimp, Crab, Fish, Milk, Nuts, Beans, potatoes, Carrots, Milk, Nuts, Beans, potatoes, Carrots, Spices, Rice, Banana, Apples, Spices, Rice, Banana, Apples, Oranges, Oranges,

Bee sting allergy usually require Bee sting allergy usually require multiple exposure but wasp sting multiple exposure but wasp sting allergy is unpredictableallergy is unpredictable

Bee sting allergy usually require Bee sting allergy usually require multiple exposure.multiple exposure.

3- None-allergic causes: ASA, NSAIDS, 3- None-allergic causes: ASA, NSAIDS, Codein, Morphine, Radiocontast Codein, Morphine, Radiocontast media, media, Vancomycin,Ciprofloxacin,Polymyxin, Vancomycin,Ciprofloxacin,Polymyxin, Anesthetics can cause histamine Anesthetics can cause histamine release.release.

Urticaria may follow: Urticaria may follow:

EBV,EBV,

HBV,HBV,

STREPTOCOCAL THROAT infection in STREPTOCOCAL THROAT infection in child,child,

Campylobacter Campylobacter

CHRONIC URTICARIA:CHRONIC URTICARIA: 1)Most cases are idiopathic1)Most cases are idiopathic 2)drugs:mostly attributable to acute 2)drugs:mostly attributable to acute

type: type: Aspirin can aggravate 20-30% of CH.U Aspirin can aggravate 20-30% of CH.U The relationship with penicilin is The relationship with penicilin is

complex and non-confirmed.complex and non-confirmed. ACEIs can cause angioedema or ACEIs can cause angioedema or

aggravate urticariaaggravate urticaria

3)reaction to additives in less than10%3)reaction to additives in less than10%(tartrazin)(tartrazin)

4)Infection:CH.U is frequently flared by 4)Infection:CH.U is frequently flared by viral infections.viral infections.

Incidence of bacterial infections such as Incidence of bacterial infections such as sinusitis, UTI ,and others are variable,sinusitis, UTI ,and others are variable,

But if present the treatment of the But if present the treatment of the infection,does not improve urticaria.infection,does not improve urticaria.

H.Pylori, candida and intestinal parasites H.Pylori, candida and intestinal parasites and toxocara are suggested but not and toxocara are suggested but not confirmed.confirmed.

5)Inhalants:Grass,pollens,mould 5)Inhalants:Grass,pollens,mould spores,animal danders,house dust spores,animal danders,house dust and even tobacco smoke are trigger and even tobacco smoke are trigger of A or CH U.of A or CH U.

If pollen allergy is proven If pollen allergy is proven desensitization may be succesfull.desensitization may be succesfull.

6)Systemic dis:CVD(SLE and 6)Systemic dis:CVD(SLE and Sjogren),IgM macroglu.Sjogren),IgM macroglu.

Neither hypo nor hyperthyroidism is commonly Neither hypo nor hyperthyroidism is commonly associated with CHU,but increased incidence of associated with CHU,but increased incidence of thyroid autoAb and disturbance of throid function thyroid autoAb and disturbance of throid function have been reported.have been reported.

There is no evidence of association with There is no evidence of association with malignancy.malignancy.

7)U may worsen premense but if it occures 7)U may worsen premense but if it occures predominantly ,it has been attributed to predominantly ,it has been attributed to progestrone sensitivity.progestrone sensitivity.

8)Flare up of U do occur at times of psychological 8)Flare up of U do occur at times of psychological stress.Depression and anxiety were found more stress.Depression and anxiety were found more frequently in CHU.frequently in CHU.

DIAGNOSISDIAGNOSIS 1)HX taking(onset,duration,and course)1)HX taking(onset,duration,and course) Weals lasting more than 24-48hr particularly Weals lasting more than 24-48hr particularly

if painful or tender suggest the possibility of if painful or tender suggest the possibility of U.vasculitis or delayed pressure U.U.vasculitis or delayed pressure U.

Location, number and shapes of wheals are Location, number and shapes of wheals are usually not helpful in most urticarias except usually not helpful in most urticarias except for small uniform short lasting weals of for small uniform short lasting weals of cholinergic urticaria or linear lesions of cholinergic urticaria or linear lesions of dermatographism .dermatographism .

A family history of atopy ,autoimmunity or A family history of atopy ,autoimmunity or angioedema may be useful.angioedema may be useful.

Physical factors should be evaluated.Physical factors should be evaluated. The presence of angioedema should The presence of angioedema should

be noted especially in pharynx or be noted especially in pharynx or larynx.larynx.

Enquire about infection, drug, Enquire about infection, drug, medication, and food.medication, and food.

INVESTIGATIONINVESTIGATION 1)Acute U: In patients with life threatening 1)Acute U: In patients with life threatening

reactions to an allergen ,confirmation is reactions to an allergen ,confirmation is possible with RAST (radioallergosorbent possible with RAST (radioallergosorbent test).test).

For moderately severe acute reaction, skin For moderately severe acute reaction, skin prick test may be helpful but is potentially prick test may be helpful but is potentially dangerous in a background of anaphylaxis .dangerous in a background of anaphylaxis .

2)Chronic U: history ,specially medications 2)Chronic U: history ,specially medications like NSAIDS.like NSAIDS.

If weals are painful and persist,with If weals are painful and persist,with present of systemic symptoms ,U vasculitis present of systemic symptoms ,U vasculitis should be considered.should be considered.

Allergy to foods is rare,but a food diary may Allergy to foods is rare,but a food diary may be helpful (time may vary from few second be helpful (time may vary from few second to 24 hr).to 24 hr).

Only a CBCdiff ,ESR (SLE,UV,MG), screening Only a CBCdiff ,ESR (SLE,UV,MG), screening test for thyroid autoAB(%14)may be test for thyroid autoAB(%14)may be worthwhile.worthwhile.

If angioedema is a major component, If angioedema is a major component, screening test for C1 sterase inhibitor screening test for C1 sterase inhibitor deficiency ,should be performed by C4.It is deficiency ,should be performed by C4.It is reduced between attacks of angioedema.reduced between attacks of angioedema.

If the weals persist for more than 48hr,and If the weals persist for more than 48hr,and not respond to antihistamines a skin biopsy not respond to antihistamines a skin biopsy may be helpful. may be helpful.

NATURAL HISTORY NATURAL HISTORY

There is no way of predicting the There is no way of predicting the duration of an attack but the severity duration of an attack but the severity is often greatest at the onset.is often greatest at the onset.

In general spontaneous improvement In general spontaneous improvement can occur in%50 within 6months.But can occur in%50 within 6months.But %50 of those associated with %50 of those associated with angioedema can still be expected to angioedema can still be expected to have their condition 10 yrs later.have their condition 10 yrs later.

Physical UrticariasPhysical Urticarias May occur so intermittently as to appear acute May occur so intermittently as to appear acute

but typically are chronic entities – most but typically are chronic entities – most idiopathicidiopathic

Physical UrticariasPhysical Urticarias– Symptomatic DermatographismSymptomatic Dermatographism– CholinergicCholinergic– Cold Induced (Familial or Acquired)Cold Induced (Familial or Acquired)– Vibratory (angioedema)Vibratory (angioedema)– Pressure – induced, Solar, AquagenicPressure – induced, Solar, Aquagenic

Physical urticaria

Symptomatic DermatographismSymptomatic Dermatographism

Simply scratching the Simply scratching the skin promotes linear skin promotes linear hives within minuteshives within minutes

Delayed form describedDelayed form described Typically is short-lived in Typically is short-lived in

duration (1/2 to 3 hours) duration (1/2 to 3 hours) and responds readily to and responds readily to antihistaminesantihistamines

Symptomatic Dermatographism

Cholinergic Urticaria

Cholinergic UrticariaCholinergic Urticaria

Goal of raising body temperature (oral) by 0.7Goal of raising body temperature (oral) by 0.7ooCC Hot bath to 42Hot bath to 4200C or having patient exerciseC or having patient exercise

Small pruritic papules result surrounded by Small pruritic papules result surrounded by erythema (but without hypotension) resulterythema (but without hypotension) result

Passive heat challenge may separate exercise-Passive heat challenge may separate exercise-induced anaphylaxis from cholinergic urticariainduced anaphylaxis from cholinergic urticaria

Methacholine skin test insensitive (positive result Methacholine skin test insensitive (positive result in only 33% of patients with cholinergic urticaria)in only 33% of patients with cholinergic urticaria)

Cholinergic urticaria

Cold-Induced UrticariaCold-Induced Urticaria

Familial (autosomal Familial (autosomal dominant) vs dominant) vs acquired (usually acquired (usually infection associated)infection associated)

Acquired form -Acquired form -positive ice-cube positive ice-cube challengechallenge

Usually responds to Usually responds to cyproheptadinecyproheptadine

Cold-induced urticaria

Cold Stimulation Time Test (CSTT)Cold Stimulation Time Test (CSTT)– Positive in acquired cold-induced urticariaPositive in acquired cold-induced urticaria– Ice cubes and water in a plastic bag applied Ice cubes and water in a plastic bag applied

to patient’s forearm up to 10 minutesto patient’s forearm up to 10 minutes– Urticaria results after warming of areaUrticaria results after warming of area– Timing of cold stimulus indirectly Timing of cold stimulus indirectly

proportional to severity (less time needed, proportional to severity (less time needed, worse symptoms upon exposure to cold)worse symptoms upon exposure to cold)

Many patients with good history for cold-Many patients with good history for cold-induced urticaria may have negative CSTTinduced urticaria may have negative CSTT

Diagnosis of cold-induced Diagnosis of cold-induced urticariaurticaria

Delayed Pressure UrticariaDelayed Pressure Urticaria

Delayed Pressure AngioedemaDelayed Pressure Angioedema

~ 37% incidence of delayed pressure ~ 37% incidence of delayed pressure urticaria in chronic urticariaurticaria in chronic urticaria

15 pound weight suspended by thick strap 15 pound weight suspended by thick strap over the shoulder and worn for 15 minutesover the shoulder and worn for 15 minutes– Typically, erythema with induration and Typically, erythema with induration and

tenderness occurs at least 2 hours after tenderness occurs at least 2 hours after the testthe test

Lawlor F et al Br J Dermatol 1989; 120: 93-99

Vibratory angioedema Vibratory angioedema

Vortex to induce angioedema in a patient with swelling of hands while driving car

MANAGEMENTMANAGEMENT

Explanation and nonspecific measures Explanation and nonspecific measures like minimizing overheating, stress like minimizing overheating, stress and alcohol may be helpful.and alcohol may be helpful.

ASA, NSAIDS,and opiates should be ASA, NSAIDS,and opiates should be avoided (paracetamol is safe).avoided (paracetamol is safe).

If allergy to food additives is If allergy to food additives is present ,a modified diet may be present ,a modified diet may be helpful.helpful.

MANAGEMENTMANAGEMENT

First line therapy:First line therapy: 1)H1 ANTIHISTAMIN:H1 is the main 1)H1 ANTIHISTAMIN:H1 is the main

mediator of urticaria which cause weal, mediator of urticaria which cause weal, itch and flare.H1 antihist are rapidly itch and flare.H1 antihist are rapidly absorbed reach to peak serum level in 2h absorbed reach to peak serum level in 2h

Traditional antihistamine have side effects Traditional antihistamine have side effects like sedation and anticholinergic and like sedation and anticholinergic and paradoxical excitation in children.paradoxical excitation in children.

HYDROXYZINE is the most potent of the HYDROXYZINE is the most potent of the classic antihist.classic antihist.

DOXEPIN is both TCA and ANTIHIST so can be DOXEPIN is both TCA and ANTIHIST so can be used in anxious patients at night but not with used in anxious patients at night but not with MAO INHMAO INH

Now the low sedative antihist are the treatment Now the low sedative antihist are the treatment of choice.of choice.

They are as effective as hydroxyzine and no They are as effective as hydroxyzine and no tolerance after continued usetolerance after continued use

Terfenadin,astemizole and mizolastin is better not Terfenadin,astemizole and mizolastin is better not be used because of Q-T prolangationbe used because of Q-T prolangation

Loratadin and cetirizin are used with the dosage Loratadin and cetirizin are used with the dosage of 10 mg/d but cetirizin is sedative and should be of 10 mg/d but cetirizin is sedative and should be used at nightused at night

NOTE THAT ANTIHIST CROSS THE NOTE THAT ANTIHIST CROSS THE PLACENTA BUT THERE IS NO PLACENTA BUT THERE IS NO EVIDENCE OF TERATOGENICITY BUT EVIDENCE OF TERATOGENICITY BUT THEY SHOULD BE AVOIDED IN THEY SHOULD BE AVOIDED IN PREGNANCY ESPECIALLY IN THE PREGNANCY ESPECIALLY IN THE FIRST TRIMEST .IF WE HAVE AN FIRST TRIMEST .IF WE HAVE AN OBLIGATION THEN OBLIGATION THEN CHLORPHENIRAMIN IS THE LEAST CHLORPHENIRAMIN IS THE LEAST RISKY.RISKY.

WE CAN USE LOW SEDATIVE WE CAN USE LOW SEDATIVE ANTIHIST AT DAY AND HIGH ANTIHIST AT DAY AND HIGH SEDATIVES AT NIGHT. SEDATIVES AT NIGHT.

A COMBINATION OF HI AND H2 A COMBINATION OF HI AND H2 BLOCKERS ARE MORE EFFECTIVE BLOCKERS ARE MORE EFFECTIVE THAN H1 ALONE.HERE RANITIDIN IS THAN H1 ALONE.HERE RANITIDIN IS A BETTER CHOICE THAN CIMETIDINA BETTER CHOICE THAN CIMETIDIN

SECOND LINE THERAPIES:SECOND LINE THERAPIES:

1)ORAL CS: in sever urticaria they are effective in 1)ORAL CS: in sever urticaria they are effective in higher doses like 0.5-1mg/kg/d short courses are higher doses like 0.5-1mg/kg/d short courses are usefull but they shouldn’t be used in long term usefull but they shouldn’t be used in long term (they are especially effective in delayed pressure (they are especially effective in delayed pressure u and u.vasculitisu and u.vasculitis

In non hereditary anioedema with respiratory In non hereditary anioedema with respiratory distress the emergency treatment is epinephrin distress the emergency treatment is epinephrin as an inhalor or IM or SC injection that can be as an inhalor or IM or SC injection that can be repeated each 10-15 minrepeated each 10-15 min

2)The choice of other second line therapies 2)The choice of other second line therapies depend on the clinical presentation .these depend on the clinical presentation .these include leukoterian receptor antagonist that include leukoterian receptor antagonist that can be used in ASA sensitivitycan be used in ASA sensitivity

3)mast cell stabilizers such as the Beta 3)mast cell stabilizers such as the Beta agonist TERBUTALIN and and Ca chanel agonist TERBUTALIN and and Ca chanel antagonist NIFEDIPINE has been combined antagonist NIFEDIPINE has been combined with H1 blockers in some patientswith H1 blockers in some patients

4)narrow band phototherapy may help some 4)narrow band phototherapy may help some

THIRD LINE THERAPY:THIRD LINE THERAPY:

In patients with sever ,nonremitting In patients with sever ,nonremitting urticaria ,not responding to urticaria ,not responding to conventional therapy conventional therapy immunomodulatory strategies can be immunomodulatory strategies can be used.used.

Plasmaphoresis improved some Plasmaphoresis improved some patients for 3-8w onlypatients for 3-8w only

IVIG 0.4g/kg/d for 5 dayIVIG 0.4g/kg/d for 5 day Cyclosporin 2.5-3.5mg/kg/d for 1-3mCyclosporin 2.5-3.5mg/kg/d for 1-3m

Physical and cholinergic uPhysical and cholinergic u

In physical urticaria a specific In physical urticaria a specific physical stimulus is presentphysical stimulus is present

Cholinergic urticaria occurs in Cholinergic urticaria occurs in response to sweating and is usually response to sweating and is usually associated with physical urticariaassociated with physical urticaria

Wealing usually occurs in minutes at Wealing usually occurs in minutes at the site of contact and lasts for 2hthe site of contact and lasts for 2h

Delayed pressure urticaria occurs in 30% Delayed pressure urticaria occurs in 30% of patients with CH.U.of patients with CH.U.

Wealing occurs at the site of sustained Wealing occurs at the site of sustained pressure to the skin after a delay of 30min pressure to the skin after a delay of 30min to 9h(4-8h)and lasts for 12-72h.to 9h(4-8h)and lasts for 12-72h.

lesions may be itchy but are often lesions may be itchy but are often tender .they often occur under tight tender .they often occur under tight clothing ,hands, buttock ,lower back and clothing ,hands, buttock ,lower back and feet.feet.

It may have systemic symptoms like It may have systemic symptoms like arthralgy ,malaise and flu like.arthralgy ,malaise and flu like.

Delayed P.U respond poorly to antihist.Delayed P.U respond poorly to antihist. Cetirizin in high doses (10mg tds), Cetirizin in high doses (10mg tds),

NSAIDS, MONTELUKAST, NSAIDS, MONTELUKAST, Colchicine ,DAPSON may be effective.Colchicine ,DAPSON may be effective.

SYS CS can be used for short courses.SYS CS can be used for short courses. The prognosis is variable and may The prognosis is variable and may

improve spontaneouslyimprove spontaneously

DERMOGRAPHISM(the response that DERMOGRAPHISM(the response that result from firm stroke of the result from firm stroke of the skin )responds well to low sedative skin )responds well to low sedative antihist but in refractory cases there antihist but in refractory cases there is no benefit from the addition of H2 is no benefit from the addition of H2 blockers.blockers.

UVB or PUVA may be effectiveUVB or PUVA may be effective

In CHOLINERGIC urticaria partial relief may In CHOLINERGIC urticaria partial relief may acheived from antihist but most have to acheived from antihist but most have to modify their life style by reducing exercise.modify their life style by reducing exercise.

KETOTIFEN is more effective than usual KETOTIFEN is more effective than usual antihist and DANAZOL may also be effective.antihist and DANAZOL may also be effective.

After each attack there may be a rafractory After each attack there may be a rafractory period for 24hperiod for 24h

In COLD urticaria, low sedative antihist, In COLD urticaria, low sedative antihist, induction of tolerance by exposure to cold induction of tolerance by exposure to cold and warning against cold bathing are useful.and warning against cold bathing are useful.

IN HEREDITARY ANGIOEDEMA IN HEREDITARY ANGIOEDEMA RESPONSE TO ORDINARY RESPONSE TO ORDINARY TRAETMENTS ARE POOR.TRAETMENTS ARE POOR.

LONG TERM PROPHYLAXIES IS WITH LONG TERM PROPHYLAXIES IS WITH DANAZOL OR STANOZOL AND SHORT DANAZOL OR STANOZOL AND SHORT TERM WITH EPSILON AMINOKAPROIC TERM WITH EPSILON AMINOKAPROIC ACID OR TRANERXAMIC ACID.ACID OR TRANERXAMIC ACID.

A PARTIALLY PURIFIED C1 EST INH A PARTIALLY PURIFIED C1 EST INH MAY BE USED DURING ATTACKS.MAY BE USED DURING ATTACKS.

Photo Images of HivesPhoto Images of Hives

Photo Images of HivesPhoto Images of Hives

Photo Images of HivesPhoto Images of Hives

Photo Images of HivesPhoto Images of Hives

Photo Image of Angioedema of FacePhoto Image of Angioedema of Face