Hives (Urticaria)


 

Hives (Urticaria) and Angioedema 

Patients with urticaria experience itchy welts of varying size on any part of their skin. This condition affects 15-20% of general population and is accompanied by angioedema (body swelling) up to half of the patients. Angioedema is not itchy but gives burning sensation deep under the skin and involves the tissues where blood supply is ample such as lips, tongue, eye socket, hands, feet, and scrotum.  Angioedema occurring alone without hives deserves special consideration.

Urticaria may be of a short duration resolving after only a few days spontaneously or in response to the elimination of the causative agents or to the administration of anti-histamines. However, the symptoms may last much longer sometimes for months or even years. When symptoms persist longer than six weeks, the condition is defined as chronic (versus acute)

Most common causes of an acute disease are drug or food hyper-sensitivities and viral diseases (see the list below).  In chronic disease, the causes cannot be found in the majority of the cases. In less than 10% of the cases, one may find causes such as physical stress (pressure, vibration, cold or warmth), hepatitis, or vasculitis (disease of small blood vessels) as in systemic lupus. In vasculitis, the hives tend to stay in one place, often involve hand and feet, and do not blanch when pressed.

Current thinking is that majority of these “idiopathic” (cause unknown) hives are due to an autoimmune phenomenon. In other words, these patients develop antibodies which attack their own skin!  This may be one reason why in 20-30% of patients, thyroid autoantibodies are found and even thyroid function may be abnormal. This can be tested by doing a skin test using patient’s own serum (Ask the lab technician to draw 0.5 ccs of extra serum and put in a test tube and bring it to Dr. Song’s office).

Although more than 2/3 of patients recover in one year, chronic urticaria is one of the most annoying and frustrating diseases for patients and doctors alike. So patients need patience and tincture of time!


Major causes of urticaria and diagnoses

  • Drug reaction:
  • Food or food additives:
  • Inhalation, ingestion, or contact with antigen
  • Infections; virus, bacteria, mycoplasma, parasite; LAB test
  • Insect bites
  • Collagen vasculitis: Lupus, serum sickness, erythema multiforme, etc: LAB tesy
  • Physical urticarias: cold, cholinergic, dermographism, pressure, vibratory, solar, aquatic
  • Malignancy; very rarely: LAB test
  • Urticaria pigmentosa: systemic mastocytosis: LAB, SKIN BIOPSY
  • Chronic idiopathic: more than half are auto-immune: Skin Test wit patient's serum

Major causes of angiodema

  • Hereditary angioedema (C1 inhibitor deficiency): LAB TEST
  • Acquired angioedema (associated malignancy): LAB TEST
  • Drug-induced (ACE inhibitors)
  • Exercise-induced
  • Idiopathic

Treatment

  • Antihistamines are the backbone of the treatment
    • Long-acting; Allegra, Claritin, Clarinex, Zyrtec (combination of the these can be used in higher doses)
    • Short-acting: Atarax is a favored one. The dose can be gradually increased up to 50 mg, 4 x/day,  to control the symptoms. Initially, patients may feel drowsy, but most get used to them.
    • For nocturnal itching, Doxepen can be used.
  • Steroid: When antihistamines alone do not control symptoms, oral steroid may be employed. Minimal effective dose needs to be used, since long-term use of steroid is associated with many side effects such weight gain, cataract, bone loss, GI bleeding, depression, adrenal suppression, etc. Once the control of symptoms is obtained, prednisone needs to be tapered gradually. However, if this is not possible, other drugs need to be added
  • Dapsone: This anti-leprosy drug can be a useful adjunctive drug.
  • Immune-suppressing drugs: If steroid does not reduce the symptoms or cannot be tapered, these agents need to be used. Most of these drugs are used as anti-cancer drugs and are associated with side effects.  Literature reports the successful use of Cytotoxan, Cyclosporin, Methotrexate, and Cellcept. Of this Cellcept probably has the least side effects.
  • IVIG (intravenous immunoglobulin G): There are reports of successful use of this product. Although the use of drug is tightly guarded acquiring review process by the insurance companies because of its limited availability and expense, it is associated with very little side effects.  The product may be given by a home health nurse at patient’s home (Crescent Home Health Care is a leading agent in our area).
  • Omalizumab (Xolair): Improves the symptoms and signs in patients with chronic idiopathic urticaria who failed to antihistamine treatment (New England J. of medicine 2/24/2013).

LAB STUDIES

Lab tests

Associated Diseases

CBC with ESR

Eosinophilia: allergy and parasites.
ESR >infections, immune complex diseases

UA

Urobilinogen in hepatitis, blood and/or protein in some vasculitis

LFT

in viral hepatitis

(TFT, thyroid antibodies)

TFT ­ or ¯ in autoimmune thyroid diseases, anti-thyroglobulin and /or anti-microsomal antibodies in thyroiditis and some euthyroid patients

 

DIAGNOSTIC CLUES


By History

Associated Diseases

Temporal relationship to drugs, foods, and contacts

Adverse reactions to, e.g,  penicillin, fish, latex, etc

Travel History

Hepatitis, parasites

History of physical exposure

Physical urticaria (Cold, heat, pressure, vibratory, aquagenic, solar, etc)

Induced by exercise

Cholinergic, exercise-induced urticaria, and anaphylaxis

History of trauma

Hereditary angioedema

Systemic illness

Viral/bacterial/mycoplasma infections, vasculitis including systemic lupus erythematosus and  serum sickness,   Henoch-Schonlein purpura

Family Hx

Hereditary angioedema, amyloidosis with deafness and urticaria, C3b inactivator deficiency

By Physical Exam

 

Size of urticaria

Cholinergic, cold-cholinergic, aquagenic, insect bites, scabies

Exposed areas

Physical urticaria (cold, dermatographism, solar, pressure, vibratory, aquagenic)

Angioedema:

Hereditary angioedema, acquired angioedema associated with malignancy, drug or contact-induced angioedema

Dependent area

Vasculitis

Involves palms and soles

Vasculitis

Thyroid enlargement

Thyroiditis

           

DISEASE MECHANISM

 

Mechanism

Hx

PE

LAB

By

 

 

 

 

By HX

 

 

 

 

 Specific antigen sensitivity

IgE mediated

Temporal relationship to ingestants or
contanctants

 

ST, RAST

 Physical urticaria
  Dermographic
  Solar
  Aquagenic
  
 

IgE mediated in some.

Temporal relationship to application of physical stimuli

Demonstrable lesions from application of physical stimuli

 

Dermographic

 

 

Demonstrated after skin is stroked.

 

solar

 

 

Demonstrated after sun light.

 

Aquatic

 

 

Demonsrated after water is applied.

 

Cholinergic

 

Exercise and heat

Application of heat
Small pin head sized wheals  frequently involving the skin of the neck.

Methacholine challenge is positive in 1/3

Exercise induced

 

Wheezing, angioedma, shock

Exercise challenge test

 

Cold urticaria

 

 

Confined to the exposed parts of the body

Ice cube test
Passive transfer of IgE

Contact urticaria

 

History of exposure to contactants

Confined to the the exposed parts of the body

Patch test

IgG mediated

 

 

 

 

 Cold

 

 

 

 

 Dermographic

 

 

 

 

Chronic idiopathic

 

Hx not helpful

 

IgG ab to IgE or IgE R

Immune complex

 

 

 

 

 Serum sickness

 

History of systemic illness

Erythema, angioedmea

¯CH50, ¯C3, ¯C4

 HAE

 

Family history(AD)
Abdominal pain

Angioedma without urticaria

¯CH50, ¯C3, ¯C4
¯C1esterase

 Acquired abgioedema

 

 

 

 

  Necrotizing vasculits

 

 

 

Skin biopsy

  Transfusion

 

Hx of transfusion

Hematuria

 

  Infection

 

Especially heaptitis

May evolve into erythema multiforme

LFT

  Cold urticaria

 

 

 

 

  Heat urticaria

 

 

 

 

Non-immunolgical

 

 

 

 

 Direct MC degranulating
   Opiates
   Amphetamines
   Polymyxin
   Curarie
   RCM

 

 

 

 

Physical Urticaria
  Pressure urticaria
 

 

 

In the area where physical force is applied such as belted area.

 

Urticaria pigmentosa

 

Early childhood

 

 

Arachdonic acid metabolism altering
  ASA
  Azo dye

 

Hx of drug ingestion

 

 


Algorithm


When the initial history/exam(1) yields a specific diagnosis, such as cholingeric urticaria or food allergy, manage accordingly. When it yields no result, do screening lab tests(2) and start symptomatic treatment. If the screening lab tests indicate a specific diagnosis such as thyroiditis or hepatitis, manage accordingly. If no etiology is found, repeat the evaluation in 6 weeks (3). If still no diagnosis is obtained, manage it as idiopathic urticaria.

Conditions Treated and Services Offered

What we treat and what we do

Location
Song Institute of Allergy, Asthma and Immunology
3113 N. Sepulveda Blvd , Suite A
South Bay

Manhattan Beach, CA 90266
Phone: 310-981-3236
Fax: (310) 802-8031
Office Hours

Get in touch

310-981-3236