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Urticaria: A Diagnostic and Therapeutic Approach American College of Physicians (ACP) October 10, 2008. Jill A. Poole, MD, FAAAAI, FACAAI Assistant Professor Pulmonary, Critical Care, Sleep & Allergy Section University of Nebraska Medical Center 402-559-4087 japoole@unmc.edu. Objectives.

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urticaria a diagnostic and therapeutic approach american college of physicians acp october 10 2008

Urticaria: A Diagnostic and Therapeutic ApproachAmerican College of Physicians (ACP)October 10, 2008

Jill A. Poole, MD, FAAAAI, FACAAI

Assistant Professor

Pulmonary, Critical Care, Sleep & Allergy Section

University of Nebraska Medical Center

402-559-4087

japoole@unmc.edu

objectives
Objectives
  • To recognize the causes of acute urticaria and angioedema
  • To recognize the causes of chronic urticaria and angioedema
  • To recognize the provocative challenges for physical urticarias
  • To discuss the treatment of urticaria and angioedema
urticaria aka hives
Urticaria (aka Hives)
  • Common problem!
    • Affects up to 20% of the population
  • Pruritic (itch!)
  • Blanche with pressure
  • Fleeting (“Leaves no trace”)

-No scarring

angioedema swelling
Angioedema (Swelling)
  • Edema of the deep layers of the dermis and subcutaneous tissue.
  • Non-pitting edema
  • Skin is not hot
  • Non-dependent areas

It is not: “pre-tibial pitting edema”

pruritus
Pruritus
  • Chronic Itch without Rash
  • Differential diagnosis is different (not chronic urticaria)
    • Uremia
    • Cholestasis
    • Malignancy
    • Non-Hodgkins Lymphoma
    • Polycythemia vera
    • Thyrotoxicosis
    • Multiple sclerosis
    • Iron Deficiency Anemia
    • Diabetes (Autonomic dysfunction)
    • Medications
    • Psychiatric Illness
slide6

Case: 35 year old man with hives for the past 4 days. Skin lesions are described as VERY itchy. Diphenhydramine helps, but does not last long, and he is taking 5-6 tablets a day. Hives began when he was eating dinner Friday night, shrimp entree. However, he has not had any shrimp since Friday night and the hives are still occurring. Plus, he has never had hives with shrimp before.No swelling, shortness of breath, throat closing, nausea, vomiting, or diarrhea.

Diagnosis?

acute urticaria
Definition: Hives lasting less than 6 weeks

Common triggers:

Foods

*Shellfish, peanut, wheat, egg,

fresh fruits, milk

Infections

More common in children

Animal dander

Pollens

DrugsAspirin, NSAIDS, antibiotics

Occupational

Stinging Insects

Acute Urticaria

Kaplan, A. P. N Engl J Med 2002;346:175-179

what do you tell the patient
What do you tell the patient?
  • It may take several weeks for the hives to go away completely.
  • Strict avoidance of shrimp.
  • Treatment with long-acting, non-sedating anti-histamines.
  • Initiate a laboratory work up to include complete blood count, complete metabolic panel, thyroid testing, urinalysis.
  • All of the above, except #4.
  • It may take several weeks for the hives to go away completely.
  • Strict avoidance of shrimp.
  • Treatment with long-acting, non-sedating anti-histamines.
  • Initiate a laboratory work up to include complete blood count, complete metabolic panel, thyroid testing, urinalysis.
  • All of the above, except #4.
slide9

Case: 18 year-old man with almost daily hives for the past 2-3 months. Hives appear after scratching the skin and last for 30-60 minutes. Sometimes hives occur along his waist when he exercises. Review of systems is otherwise negative.

Diagnosis?

slide10

DermatographismA Physical Urticaria

Scratching skin results in hives lasting 30 mins to 2 hours

Kaplan, A. P. N Engl J Med 2002;346:175-179

physical urticarias
Physical Urticarias
  • Reproducible by environmental factors
    • Physical stimuli
  • Most frequently in young adults
  • Episodic and often limited to areas of inciting stimulus
  • Usually, unresponsive to corticosteroids
  • Overall, treatment with non-sedating antihistamines
examples of physical urticarias
Examples of Physical Urticarias

1. If you stroke the skin, and a hive occurs?

Answer: Dermatographism

2. If you place an ice cube on the forearm, and after removal of ice cube, hive occurs?

Answer: Cold-induced urticaria

3. If hives occur when the patient sweats or exposure to heat?

Answer: Cholinergic urticaria or localized heat urticaria

more examples of physical urticaria
More Examples of Physical Urticaria

4. If shoulder swells (angioedema) 4-6 hours after carrying a heavy shoulder bag?

Answer: Delayed pressure-induced urticaria & angioedema

Note: may require cortiosteroids

5. If patient develops hives only while mowing the lawn?

Answer: Vibratory-induced urticaria

slide14
Case:8 year old boy with numerous pruritic small lesions on arms and legs. A flea collar was placed on Fluffy, the cat, yesterday.
  • Papular urticaria
  • A hypersensitivity reaction to the bites of mosquitoes, fleas, bedbugs, and other insects causes papular urticaria.

Diagnosis?

Treatment: Treat the cat

slide15

Case: 34 year-old woman with almost daily hives for the past five to six months. She occasionally has associated right upper lip swelling, but denies dyspnea or throat swelling/closing. She states hives occur randomly. She takes 5-6 tablets of diphenhydramine a day. Review of systems is otherwise negative.

Diagnosis?

Etiology?

chronic urticaria angioedema
Chronic Urticaria & Angioedema
  • Definition: Hives occurring greater than 6 weeks
    • Hives and angioedema (40%)
    • Hives alone (40%)
    • Angioedema alone (20%)

Etiology:

  • Difficult to determine, cause rarely found
  • Common in 3rd and 4th decade of life
  • Usually not foods, drugs, pollens, infections, “dyes”
  • Bad News: May last years….
chronic urticaria angioedema1
Chronic Urticaria & Angioedema

Thyroid Disease Association

Thyroid function tests

Thyroid autoantibodies

Hives: 4 to 36 hours?

Autoimmune

Autoantibodies to the high affinity IgE receptor (40%)

Hives: 4 to 36 hours

Idiopathic*

Hives: 4 to 36 hours

Urticarial Vasculitis

Systemic or isolated

Hives: > 24 hours

Faint hyperpigmentation

Kaplan, A. P. N Engl J Med 2002;346:175-179

chronic urticaria diagnostic evaluation
Chronic Urticaria Diagnostic Evaluation
  • History & Physical Exam
    • Diary
    • Relationship of hives with menstrual cycle?
  • Provocative tests for physical causes
  • Laboratory tests:

(Not proven to be cost effective)

    • CBC with diff, ESR, CRP, UA, LFTs
    • Thyroid function, anti-thyroid antibodies
    • Skin tests
    • Autologus serum skin test
    • Complements
chronic urticaria diagnostic evaluation1
Chronic Urticaria Diagnostic Evaluation
  • Skin biopsy?
    • Generally, not helpful
  • Indications:
    • Lesions lasting more than 24 to 48 hours
    • Atypical?
    • Scarring
    • Red blood cell extravasation
    • Cutaneous vasculitis
    • Urticaria pigmentosa
  • Refractoriness to therapy
chronic autoimmune urticaria
Chronic Autoimmune Urticaria
  • Functional antibody (IgG)

to the alpha subunit of the

high affinity IgE receptor (30%)

  • Functional anti-IgE antibody (5-10%)
  • Diagnosis
    • Immunoblotting has been unsuccessful
    • Autologous serum skin testing (ASST)
      • Intradermal injection of subject’s serum
      • Wheal and flare reaction after 30 minutes
    • Basophil CD203c Expression

Greaves, JACI 2000; Kaplan, NEJM 2002

management of chronic urticaria angioedema
Management of Chronic Urticaria/Angioedema
  • Avoidance or treatment of underlying cause
  • Avoidance of potentiating factors
    • Alcohol
    • Non-steroidal anti-inflammatory drugs
  • Main therapy
    • H1 anti-histamines
      • Non-sedating, long-acting antihistamines
  • Combination of therapies
    • Triple drug therapy: H1 & H2 antagonists plus leukotriene blockers
    • Tricyclic antidepressants
    • Immunomodulators (e.g. steroids, cyclosporine)
      • Tried with “?” benefit: Hydroxychloroquine, dapsone, calcium channel blockers, methotrexate, colchicine, pentoxyfilline, cyclophosphamide
urticarial vasculitis rare
Urticarial Vasculitis (Rare)
  • Inflammatory injury of capillaries and postcapillary venules in the skin.
  • Etiology: Manifestation of systemic disease
  • Clinically:
    • Hives persisting > 24 hours
    •  pruritic
    • Painful, stinging, burning sensation
    • “Leaves a trace”
      • Faint residual hyperpigmentation, indicating red blood cell extravasation
conclusions
Conclusions
  • Hives
    • Very common
  • Acute Urticaria (Hives < 6 weeks)
    • History is key
    • Non-sedating anti-histamines
  • Physical Urticarias
    • History and provocative challenges
    • Non-sedating histamines
  • Chronic Urticaria (Hives > 6 weeks)
    • Etiology: Rarely determined
    • Therapy: Difficult