‫به نام خداوند جان و خرد‬
ِِDr Anahita Vali
Dermatologist & venereologist
Urticaria is a transient element
Is it transient???
Less than 24 hours
MARKING AROUND THE LESIONS
Urticaria is a
cutaneous reaction pattern

(from the Latin urtica,
nettle,] commonly referred
to as hives,
 is a kind of skin rash
notable for pale red, raised,
itchy bumps. Hives might
also cause a burning or
stinging sensation. Hives
are frequently caused by
allergic reactions; however,
there are many nonallergic
causes.
Why transient &
itching???
 How
Long???
Most cases of hives lasting
less than six weeks
(acute urticaria) are the
result of an allergic trigger.
Chronic urticaria (hives
lasting longer than six weeks)
is rarely due to an allergy.
Clinical findings



Distribution
 Any body site
Morphology
 Central, oedematous plaques without scale
(a wheal) and surrounding redness (a flare)
 Annular lesions result from central clearing
 Lesions vary in size, some can be very large
Can be associated with angioedema, and
much less commonly anaphylaxis. Anaphlaxis
is defined by a progressive reaction with rash,
breathing difficulties and cardiovascular
compromise. The most common causes of
anaphylactic reactions are in the following
order:
 Food allergy
 Drugs
 Stings / bites

The majority of chronic hives cases
have an unknown (idiopathic) cause.
 In perhaps as many as 30–40% of
patients with chronic idiopathic
urticaria, it is caused by an
autoimmune reaction.
 Acute viral infection is another
common cause of acute urticaria (viral
exanthem).
 Less common causes of hives
include friction, pressure,
temperature extremes,
exercise, and sunlight.
slightly raised, no scale
What is the differences?
Wheals (raised areas surrounded
by a red base) from urticaria can
appear anywhere on the surface of
the skin. Whether the trigger is
allergic or not, a complex release of
inflammatory mediators, including
histamine from cutaneous mast
cells, results in fluid leakage from
superficial blood vessels. (welldemarcated,erythmatousus)
Wheals may be pinpoint in size, or
several inches in diameter.
itching
Angioedema
is a related
condition (also from allergic and
nonallergic causes), though fluid
leakage is from much deeper
blood vessels in the
subcutaneous or
submucosal layers.(poorly
–defined borders)
Usually mucosa, lips, palm
&soles/lids/genitalia/tongue
/larynx/GI/GU/painful




Hives during life: 20-25%
All age groups
Acute urticaria more
common in children &
young adults
Chronic urticaria is more
prevalent in adults/F>M



How many percent of Pts
are free of chronic
urticaria after 1 years???
After 5 years???
& after 20 years???
Conclusion: If urticaria associated
with angioedema is more persistent.
Urticaria alone :40%
 Urticaria & angioedema :49%
 Angioedema alone:11%
 Some of the more severe
chronic cases have lasted
more than 20 years. A survey
indicated chronic urticaria
lasted a year or more in more
than 50% of sufferers and 20
years or more in 20% of them.


Morbidity depends on
the severity and
duration of the
condition. One study
found that urticaria
patients can have as
much psychologic,
social, and
occupational distress
as patients who are
awaiting triple
coronary artery
bypass surgery.


Urticaria can also be
classified by the
purported causative
agent. Many different
substances in the
environment may cause
urticaria, including
medications, food and
physical agents.
After contact with a
Conifer
Management

Avoid triggers

Use non-sedating

antihistamines PRN
Occasionally a short course of oral steroids (prednisolone) may
be needed


Patients with anaphylaxis will often be diagnosed at an accident and
emergency department. Such patients should be provided with two
Epipens and relevant advice on how to manage an attack including how to
use an Epipen
Some patients will benefit from a referral to an immunologist / paediatrician,
for example:
 Patients with moderate-severe reactions to eggs
 Patients with nut allergies, who often have multiple allergies and may
require further investigations
 Other cases of life-threatening reactions
Drug-induced urticaria

Drugs that have caused
allergic reactions evidenced as
urticaria include
dextroamphetamine,aspirin,
ibuprofen, penicillin,
clotrimazole, sulfonamides,
anticonvulsants, cefaclor and
antidiabetic drugs. The
antidiabetic sulphonylurea
glimepiride (trade name
Amaryl), in particular, has been
documented to induce allergic
reactions manifesting as
urticaria. Drug-induced
urticaria has been known to
have an effect on severe
cardiorespiratory
failure.
Infection or environmental agent
Urticaria can be a complication and
symptom of a parasitic infection,
such as fascioliasis (Fasciola
hepatica) and ascariasis (Ascaris
lumbricoides).
 The rash that develops from poison
ivy, poison oak, and poison sumac
contact is commonly mistaken for
urticaria. This rash is caused by
contact with urushiol and results in
a form of contact dermatitis called
urushiol-induced contact
dermatitis.
 Urushiol is spread by contact, but
can be washed off with a strong
grease- or oil-dissolving
detergent and cool water and
rubbing ointments.

Dermatographic urticaria
"skin writing")

Hives caused by
 stroking the skin
 (often linear in
appearance)
 are due to a benign
condition
 in 4–5% of the population
 usually becomes evident
soon after the scratching,
and disappears within 30
minutes.
Dermatographism is the most common
form of a subset of chronic hives,
acknowledged as "physical hives

It stands in contrast to the linear
reddening that does not itch
seen in healthy people who are
scratched. In most cases, the
cause is unknown, although it may
be preceded by a viral infection,
antibiotic therapy, or emotional
upset. Dermographism is
diagnosed by taking a tongue
blade and drawing it over the skin
of the arm or back. The hives
should develop within a few
minutes. Unless the skin is highly
sensitive and reacts continually,
treatment is not needed. Taking
antihistamines can reduce the
response in cases that are
annoying to the patient.
Pressure or delayed pressure
urticaria

This type of urticaria can occur right away, precisely
after a pressure stimulus or as a deferred response to
sustained pressure being enforced to the skin. In the
deferred form, the hives only appear after about
six hours from the initial application of pressure to

the skin.
Under normal circumstances, these hives are not the
same as those witnessed with most urticariae.
Instead, the protrusion in the affected areas
is typically more spread out. The hives may last
from eight hours to three days. The source of
the pressure on the skin can happen from tight fitted
clothing, belts, clothing with tough straps, walking,
leaning against an object, standing, sitting on a hard
surface, etc. The areas of the body most commonly
affected are the hands, feet, trunk, abdomen,
buttocks, legs and face. Although this appears
to be very similar to dermatographism, the cardinal
difference is that the swelled skin areas do not become
visible quickly and tend to last much longer. This form
of the skin disease is, however, rare.
Treat your pts based on
pathophysiology
PMN-RICH URTICARIA
LYMOCYTE & MAST-CELL
RICH URTICARIA
urticarial vasculitis




Individual hives that are
painful,
last more than 24 hours
leave a bruise as they heal are more
likely to be a more serious condition
Cholinergic or stress


Cholinergic urticaria (CU) is one of the
physical urticaria which is provoked
during sweating events such as
exercise, bathing, staying in a heated
environment, or emotional stress. The
hives produced are typically smaller than
classic hives and are generally shorterlasting.
Multiple subtypes have been elucidated,
each of which require distinct treatment.
Sudden death after diving
Cold-induced





is caused by exposure of the skin to extreme cold, damp and windy
conditions; it occurs in two forms.
The rare form is hereditary and becomes evident as hives all over
the body 9 to 18 hours after cold exposure.
The common form of cold urticaria demonstrates itself with the
rapid onset of hives on the face, neck, or hands. Cold
urticaria lasts for an average of five to six years. The population most
affected is young adults, between 18 and 25 years old. Many people
with the condition also suffer from dermographism and cholinergic
urticaria.
Severe reactions can be seen with exposure to cold water; swimming
in cold water is the most common cause of a severe reaction. This
can cause a massive discharge of histamine, resulting in low blood
pressure, fainting, shock and even loss of life. Cold urticaria is
diagnosed by dabbing an ice cube against the skin of the forearm
for 1 to 5 minutes. A distinct hive should develop if a patient suffers
cold urticaria. This is different than the normal redness that can be seen
in people without cold urticaria.
Patients with cold urticaria need to learn to protect themselves from a
hasty drop in body temperature. Regular antihistamines are not
generally efficacious. One particular antihistamine,
cyproheptadine (Periactin), has been found to be useful. The
tricyclic antidepressant doxepin .Finally, ketotifen, which keeps
mast cells from discharging histamine, has also been employed with
widespread success.
Heat-induced urticaria


This rare form of urticaria is
triggered by the continued
application of heat on the
skin.
Hives begin to appear within
two to five minutes
on the area of the skin
exposed to heat.

Do not last more than an
hour.
Solar urticaria
This form of the disease occurs on areas of
the skin exposed to the sun;
 the condition becomes evident within
minutes of exposure. After the
individual is no longer exposed to the sun,
though, the condition starts to weaken within
a few minutes to a few hours, and hardly
ever lasts longer than 24 hours.
 Solar urticaria is classified into six

different types, depending upon
the wavelength of light involved.

Since glass absorbs light with a
wavelength of 320 nm and below,
people suffering from solar urticaria in
response to wavelengths of less than
320 nm are protected by glass.

Water urticaria
rare, and occurs upon contact with water.
The response is not temperature-dependent and
the skin appears similar to cholinergic form of the
disease. The appearance of hives is within one to
15 minutes of contact with the water, and can last
from 10 minutes to two hours. The hives that last
for 10 to 120 minutes do not seem to be
stimulated by histamine discharge like the other
physical hives. Most researchers believe this
condition is actually skin sensitivity to additives in
the water, such as chlorine.
 diagnosed by dabbing tap water and distilled
water to the skin and observing the gradual
response. Aquagenic urticaria is treated with
capsaicin (Zostrix) administered to the
chafed skin. This is the same treatment used for
shingles. Antihistamines are of questionable
benefit in this instance, since histamine is
not the causative factor.
Exercise urticaria
hives, itchiness, shortness of breath and low blood
pressure five to 30 minutes after beginning exercise.
These symptoms can progress to shock and even
sudden death. Jogging is the most common exercise to
cause EU, but it is not induced by a hot shower, fever, or with
fretfulness. This differentiates EU from cholinergic urticaria
EU sometimes occurs only when someone exercises within 30
minutes of eating particular foods, such as wheat or shellfish.
For these individuals, exercising alone or eating the injuring food
without exercising produces no symptoms. EU can be diagnosed
by having the patient exercise and then observing the
symptoms. This method must be used with caution and only with
the appropriate resuscitative measures at hand. EU can be
differentiated from cholinergic urticaria by the hot water
immersion test. In this test, the patient is
immersed in water at 43°C (109.4°F). Someone with EU
will not develop hives, while a person with cholinergic urticaria
will develop the characteristic small hives, especially on the neck
and chest
The immediate symptoms of this uncanny type are treated with
antihistamines, epinephrine and airway support.
Taking antihistamines prior to exercise may be
effective. Ketotifen is acknowledged to stabilise mast cells
and prevent histamine release, and has been effective in treating
this hives disorder. Avoiding exercise or foods that cause the
mentioned symptoms is very important. In particular
circumstances, tolerance can be brought on by regular exercise,
but this must be under medical supervision
Food urticaria

The most common
food allergies in adults
are shellfish and nuts.
The most common
food allergies in
children are shellfish,
nuts, peanuts, eggs,
wheat, and soy. A less
common cause is
exposure to certain
bacteria, such as
Streptococcus species
or possibly
Helicobacter pylori.
Vibratory angioedema & urticaria
This very rare form of angioedema
develops in reply to contact with vibration.
In vibratory angioedema, symptoms
develop within two to five
minutes after contact with
vibration and dissolve after
about an hour. Patients with this
disorder do not suffer from
dermographism or pressure urticaria.
Vibratory angioedema is diagnosed by
holding a vibrating device such as a
laboratory vortex machine against the
forearm for four minutes. Speedy swelling
of the whole forearm extending into the
upper arm is also noted later. The
principal treatment is avoidance of
vibratory stimulants. Antihistamines
have also been proven helpful.
Pathophysiology
The skin lesions of urticarial
disease are caused by an
inflammatory reaction in the
skin, causing leakage of
capillaries in the dermis, and
resulting in an edema which
persists until the interstitial
fluid is absorbed into the
surrounding cells.
 Urticaria is caused by the
release of histamine and
other mediators of
inflammation (cytokines) from
cells in the skin. This process
can be the result of an

allergic or nonallergic
reaction, differing in the
eliciting mechanism of
histamine release
Autoimmune urticaria

In the past decade, many
cases of chronic idiopathic
urticaria have been noted
to be the result of an
autoimmune trigger. For
example, roughly one-third
of patients with chronic
urticaria spontaneously
develop autoantibodies
directed at the receptor
FcεRI located on skin mast
cells. Chronic stimulation
of this receptor leads to
chronic hives. Patients
often have other
autoimmune conditions,
such as autoimmune
thyroiditis.
Nonallergic urticaria




Mechanisms other than allergen-antibody
interactions are known to cause
histamine release from mast cells. Many
drugs, for example morphine, can induce
direct histamine release not involving any
immunoglobulin molecule.
Also, a diverse group of signaling
substances, called neuropeptides, have
been found to be involved in
emotionally induced urticaria.
Dominantly inherited cutaneous and
neurocutaneous porphyrias (porphyria
cutanea tarda, hereditary coproporphyria,
variegate porphyria and erythropoietic
protoporphyria) have
been associated with solar urticaria. The
occurrence of drug-induced solar urticaria
may be associated with porphyrias. This
may be caused by IgG binding, not IgE.
Nonallergic release of mediators

A number of drugs, such as
aspirin, NSAIDs, opiates,
succinylcholine, and certain
antibiotics (eg, polymyxin,
ciprofloxacin, rifampin,
vancomycin, some betalactams) can cause urticaria by
a nonallergic mechanism rather
than by IgE-mediated
hypersensitivity.
 Certain foods or beverages, such
as spoiled fish (scombroidosis),
aged cheeses, or red wine, can
contain histidine,
 Certain venoms may cause
urticaria.
 Radiocontrast media sensitivity is
not related to iodine, fish, or
Medical causes




Urticaria has been reported with
infectious diseases.
Viral infections associated with
acute urticaria include acute viral
syndromes, hepatitis (A, B, and
C), Epstein-Barr virus, and
herpes simplex virus.
Streptococcal infection has been
reported as the cause of 17% of
acute urticaria cases in children.
Urticaria associated with acute group A
Urticaria has also been reported beta-hemolytic streptococci infection.
with chronic parasitic infections.
sinusitis, cutaneous fungal
infections, Helicobacter pylori
infection, or other occult infections
Hormonal causes

Hormonal causes via endocrine
tumors or ovarian pathology
are rare. Oral contraceptive
use or changes in the
menstrual cycle have been
reported as a possible cause of
urticaria: patients commonly
report worsening of hives with
the menstrual cycle. This may
be hormonally mediated,
and the cyclical use of
analgesics should also be
considered as a possible
etiology
Dangerous causes of urticaria

Urticaria can be the
presenting symptom
of lymphoma, and
a careful history and
review of systems is
important.
Rare causes of urticaria







Cryoglobulinemias (eg, associated with
hepatitis C, chronic lymphocytic leukemia)
Serum sickness
Other immune complex–mediated
inflammation
Systemic lupus erythematosus,
rheumatoid arthritis, juvenile rheumatoid
arthritis, or other rheumatologic diseases
(rare causes of urticaria)
Hypothyroidism and hyperthyroidism,
although euthyroid patients with
antithyroid antibodies (ie, vide infra) can
be affected
Lymphoreticular malignancies (eg, chronic
lymphocytic leukemia)
Pregnancy (ie, pruritic urticarial papules
and plaques of pregnancy [PUPPP]
Physical causes (physical urticaria)








Cold
Pressure
Vibration
Cholinergic (triggered
by heat, exercise, or
emotional stress)
Sunlight
Water
Dermographism (can
occur as an isolated
condition)
Exercise
Hereditary angioedema

(C1 inhibitor
deficiency) accounts
for only 0.4% of
cases of
angioedema but is
associated with a
high mortality rate.
Dietary histamine poisoning

This is termed
scombroid food
poisoning. Ingestion
of free histamine
released by bacterial
decay in fish flesh
may result in a rapidonset, allergic-type
symptom complex
which includes
urticaria. However, the
urticaria produced by
scombroid is reported
not to include wheals
Drug allergies


Theoretically, almost any drug
can cause an allergic reaction
thus, allergic reactions to a wide
variety of drugs can
occur.Antibiotics, such as
penicillin, have been
implicated most frequently.
Urticarial reactions to penicillin
can occur as long as 14 days
after a course of
treatment has stopped. In
this situation, serum
sickness may be present.
Stress and chronic idiopathic
urticaria
Chronic idiopathic urticaria has
been anecdotally linked to stress
since the 1940s.[
 A large body of evidence
demonstrates an association
between this condition and both
poor emotional well-being and
reduced health-related quality of
life.
 A recent study has demonstrated
an association between stressful
life events (e.g. bereavement,
divorce, etc.) and chronic idiopathic
urticaria and also an association
between post-traumatic stress and
chronic idiopathic urticaria.

Management
Chronic urticaria can be difficult to treat.
No guaranteed treatments or
means of controlling attacks are available,
and some subpopulations are treatmentresistant, with medications spontaneously
losing their effectiveness and requiring new
medications to control attacks.

It can be difficult to determine appropriate
medications, since some, such as loratadine,
require a day or two to build up to effective
levels, and the condition is intermittent and
outbreaks typically clear up without any
treatment.
 Most treatment plans for urticaria involve
being aware of one's triggers, but this can be
difficult, since several forms of urticaria are
known and people often exhibit more than one
type. Also, since symptoms are often
idiopathic, a clear trigger is often unknown. If
triggers can be identified, then outbreaks can
often be managed by limiting exposure
to them.

Patient Education

Avoidance of known
triggering factors is
important, and patients
with urticaria should be
discouraged from
scratching or
irritating the skin
when active lesions are
present. Pressure
urticaria may worsen the
intensity of the rash;
therefore, avoiding
tight-fitting clothes
may be helpful.
Allergy tests
Physicians can rarely
determine any particular
cause of disease for chronic
urticaria.
 In some cases, patients or
doctors come to request
regular extensive allergy
testing over a long period of
time in hopes of getting new
insight.
 No evidence shows regular
allergy testing results in
identification of a problem or
relief for people with chronic
urticaria.
 Regular allergy testing for
people with chronic urticaria

is not recommended.
Antihistamines


Antihistamines such as
diphenhydramine may be
used.
The benefit of H2
receptor antagonists
such as ranitidine is
poorly supported by the
evidence.
Other treatments







Tricyclic antidepressants, such as doxepin, also are often potent H1 and H2 antagonists and may
have a role in therapy, although side effects limit their use. For very severe outbreaks, an oral
corticosteroid such as prednisone is sometimes prescribed. However, this form of treatment is
controversial because of the extensive side effects common with corticosteroidsis not a
recommended long-term treatment option.
For acute urticaria, some topical creams, such as hydrocortisone, fluocinonide, or desonide, to
relieve itching. To boost relief for severe anaphylactic urticaria, a dermatologist will also administer
steroid shots intramuscularly.
analogue of alpha-melanocyte-stimulating hormone called afamelanotide (for the treatment of solar
urticaria, a type of urticaria that develops in response to exposure to specific wavelengths of light.
Therapy-refractory cases with urticaria may sometimes respond to unusual drugs, such as
dapsone
A diet reduced in allergens like salicytes, grains, and the 8 most common food allergens may also
help to reduce symptoms. Chronic Idiopathic Urticaria and treatment with an oligoantigenic
diet. an allergen-restricted diet saw their urticaria decrease significantly or vanish entirely.
Acute urticaria induced by the use of trichazole only reacted to treatment by taking a very hot bath in
water containing epsom salts and other vitamins and minerals known to induce exfoliation.
Application of lemon juice brought temporary relief from itching and Epizone A cetomacrogol cream
was the most effective topical application, after the heat treatment. [
]the anti-asthma drug omalizumab showed promise in relieving symptoms for patients with
chronic idiopathic urticaria whose symptoms were not relieved with antihistamine treatment.
Anaphylaxis
Urticaria can be one of the first
symptoms of a severe allergic reaction
known as anaphylaxis.
 swelling of your eyes, lips, hands and
feet
 narrowing of your airways which can
cause breathing difficulties and wheezing
 a feeling of impending doom as if
something terrible is going to happen
 Anaphylaxis should always be treated as
a medical emergency. immediately dial

115 for an ambulance and tell the
operator that you think anaphylaxis has
occurred.
the moulds on
any cheeses
or aged foods
apparently
contain lots of
histamines
 avoid food
containing

vasoactive
amines
‫من مي خورم و هر كه چو من اهل بود‬
‫مي خوردن من به نزد او سهل بود‬
‫مي خوردن من حق ز ازل مي دانست‬
‫گر مي نخورم علم خدا جهل بود‬
Contact urticaria

Contact urticaria is
an allergic reaction
to a substance that
comes into contact
with the skin (eg, an
occupational

exposure)
Latex in physicians
,nurses & dentist
Local urticaria on a patient with latex
allergy who was touched with a latex glove.
Papular urticaria


Insect bites
Papular urticaria is a
variation of urticaria
caused by insect
bites the lesions
may last longer
than 24 hours.

Urticaria developed
after bites from an
imported fire ant.
Urticaria pigmentosa
Thank you for your attention
‫اين همه گفتيم ليك اندر بسيچ‬
‫بي عنايات خدا هيچيم هيچ‬