Introduction: Urticaria and Angioedema
Urticaria
Angioedema
Etiology of Urticarial Reactions: Allergic Triggers
Acute Urticaria
Drugs Foods
Chronic Urticaria
Food additives
Viral infections hepatitis A, B, C Epstein-Barr virus
Physical factors cold heat dermatographic pressure solar
Idiopathic
Insect bites and stings
Contactants and inhalants (includes animal dander and latex)
The Pathogenesis of Chronic Urticaria: Cellular Mediators
Histamine as a Mast Cell Mediator
Role of Mast Cells in Chronic Urticaria: Lower Threshold for Histamine Release
Cutaneous mass cell
Release threshold decreased by:
Cytokines & chemokines in the cutaneous microenvironment Antigen exposure Histamine-releasing factor Autoantibody Psychological factors
Release threshold increased by:
Corticosteroids Antihistamines Cromolyn (in vitro)
An Autoimmune Basis for Chronic Idiopathic Urticaria: Antibodies to IgE
Initial Workup of Urticaria
Patient history
Physical exam
Sinusitis Arthritis Thyroid disease Cutaneous fungal infections Urinary tract symptoms Upper respiratory tract infection (particularly important in children) Travel history (parasitic infection) Sore throat Epstein-Barr virus, infectious mononucleosis Insect stings Foods Recent transfusions with blood products (hepatitis) Recent initiation of drugs
Skin Eyes Ears Throat Lymph nodes Feet Lungs Joints Abdomen
Laboratory Assessment for Chronic Urticaria
Initial tests
CBC with differential Erythrocyte sedimentation rate Urinalysis
Possible tests for selected patients
Stool examination for ova and parasites Blood chemistry profile Antinuclear antibody titer (ANA) Hepatitis B and C Skin tests for IgE-mediated reactions
RAST for specific IgE Complement studies: CH50 Cryoproteins Thyroid microsomal antibody Antithyroglobulin Thyroid stimulating hormone (TSH)
Histopathology
Group 2:
Polymorphous perivascular infiltrate Neutrophils Eosinophils Mononuclear cells
Group 3:
Sparse perivascular lymphocytes
Urticaria Associated With Other Conditions
Collagen vascular disease (eg, systemic lupus erythematosus) Complement deficiency, viral infections (including hepatitis B and C), serum sickness, and allergic drug eruptions Chronic tinea pedis Pruritic urticarial papules and plaques of pregnancy (PUPPP) Schnitzlers syndrome
H1-Receptor Antagonists: Pros and Cons for Urticaria and Angioedema
First-generation antihistamines (diphenhydramine and hydroxyzine)
Advantages: Rapid onset of action, relatively inexpensive Disadvantages: Sedating, anticholinergic
Second-generation antihistamines (astemizole, cetirizine, fexofenadine, loratadine)
Advantages: No sedation (except cetirizine); no adverse anticholinergic effects; bid and qd dosing Disadvantages: Prolongation of QT interval; ventricular tachycardia (astemizole only) in a patient subgroup
Four-week Treatment Period: Fexofenadine HCl
Mean Pruritus Scores/Mean Number of Wheals/Mean Total Symptom Scores
An Approach to the Treatment of Chronic Urticaria
Treatment of Urticaria: Pharmacologic Options
Antihistamines, others
First-generation H1 Second-generation H1 Antihistamine/decongestant combinations Tricyclic antidepressants (eg, doxepin) Combined H1 and H2 agents
Corticosteroids
Severe acute urticaria avoid long-term use use alternate-day regimen when possible Avoid in chronic urticaria (lowest dose plus antihistamines might be necessary)
Beta-adrenergic agonists
Epinephrine for acute urticaria (rapid but short-lived response) Terbutaline
Miscellaneous
PUVA Hydroxychloroquine Thyroxine
Atopic Dermatitis: Acute, Subacute, and Chronic Lesions
Acute Cutaneous Lesions
Erythematous, intensely pruritic papules and vesicles Confined to areas of predilection cheeks in infants antecubital popliteal
Subacute Cutaneous Lesions
Erythema excoriation, scaling Bleeding and oozing lesions
Chronic Lesions
Excoriations with crusting Thickened lichenified lesions Postinflammatory hyperpigmentation Nodular prurigo
Atopic Dermatitis: Physical Distribution by Age Group
Immune Response in Atopic Dermatitis
Markedly elevated serum IgE levels
Peripheral blood eosinophilia
Highly complex inflammatory responses > IgE-dependent immediate hypersensitivity Multifunctional role of IgE (beyond mediation of specific mast cell or basophil degranulation) Cell types that express IgE on surface monocyte/macrophages Langerhans cells mast cells basophils
Atopic Dermatitis: Tests to Identify Specific Triggers
Skin prick testing for specific environmental and/or food allergens RAST, ELISA, etc, to identify serum IgE directed to specific allergens in patients with extensive cutaneous involvement Tzanck smear for herpes simplex
KOH preparation for dermatophytosis
Grams stain for bacterial infections Culture for antibiotic sensitivity for staphylococcal infection; supplement with bacterial cultures
Cultures to support tests bacterial, viral, or fungal
Topical Corticosteroids
Ranked from high to low potency in 7 classes Group 1 (most potent): betamethasone dipropionate 0.05% Group 4 (intermediate potency): hydrocortisone valerate 0.2% Group 7 (least potent): hydrocortisone hydrochloride 1% Local side effects: Development of striae and atrophy of the skin, perioral dermatitis, rosacea Systemic effects: Depend on potency, site of application, occlusiveness, percentage of body covered, length of use May cause adrenal suppression in infants and small children if used long term
Antihistamines and Other Treatments
Standard Treatment
Oral antihistamines to relieve itching Moisturizer to minimize dry skin Topical corticosteroids
Hard-to-manage Disease
Antibiotics Coal tar preparations (antipruritic and anti-inflammatory) Wet dressings and occlusion Systemic corticosteroids UV light therapy Hospitalization
