Chronic inducible urticaria: Clinical presentation, diagnosis, and management

Chronic inducible urticaria (CIndU) is a subtype of chronic urticaria characterized by recurrent itchy wheals and/or angioedema for more than 6 weeks. CIndU has a longer disease duration than chronic spontaneous urticaria (CSU) and wheals are shorter lasting than CSU. CIndU incudes physical and non-physical urticaria. Triggers and diagnosis of subtypes of CIndU differ from each other. Patient education for avoiding triggers is an important aspect of the treatment of CIndU. There is no significant difference in the treatment approach for CIndU and CSU. In this article, we have discussed different types of CIndU, their clinical features, diagnosis, and management.

Aquagenic Urticaria Treated with Omalizumab

Aquagenic urticaria is a rare form of physical urticaria in which a 1-2 mm wheal is produced by contact with water. Treatment options include antihistamines, ultraviolet monotherapy, topical barrier creams, and acetylcholine antagonists. Despite these pharmacologic measures, the symptoms are frequently refractory to therapy. Aquagenic urticaria lowers the patient’s quality of life and causes daily discomfort. Recently, a patient with aquagenic urticaria treated with omalizumab was reported. Here, we describe a 22-year-old man with a 3-year history of aquagenic urticaria confirmed by a water immersion test. Because he showed no improvement with antihistamines, the patient began omalizumab treatment and demonstrated an excellent response. This case provides new information for clinicians.

Anaphylaxis Caused by Swimming: A Case Report of Cold-induced Urticaria in the Emergency Department

Introduction: Cold-induced urticaria is a subset of physical urticaria that presents as wheals or angioedema in response to cold exposure. While most cases are idiopathic, secondary associations with infections, medications, and certain cancers have been described. Case Report: We discuss the case of a 50-year-old male with recent episodes of urticaria from cold air exposure following a flu-like illness six months prior, who presented with symptoms of anaphylaxis upon jumping into a lake. Conclusion: While the majority of patients develop localized symptoms, understanding this disease entity is imperative as up to one-third of patients can develop severe symptoms including anaphylaxis, particularly from water submersion during activities such as swimming.

Chronic urticaria: a clinico-etiological study and autologous serum skin test role in chronic idiopathic urticaria

<p class="abstract"><strong>Background:</strong> Appearance of wheals daily for more than six weeks is chronic urticarial (CU). No cause is identified in about 50-70% of chronic urticaria patients and are labelled as chronic idiopathic urticaria (CIU). The aim of the present study is to study the clinical and etiological pattern of chronic urticaria and to find out the incidence of autoimmune urticaria by performing autologous serum skin test (ASST) in patients with CIU.</p><p class="abstract"><strong>Methods:</strong> This was a cross sectional study enrolling 100 chronic urticaria patients satisfying including and excluding criteria. The study was done for a period of 1 year. ASST was done in all the CIU patients after recording detailed history, complete physical and systemic examination.</p><p class="abstract"><strong>Results:</strong> Most of the patients (33%) were in 21-30 years age group with female preponderance (66%). Students (38%) followed by house wives (27%) were majorly involved. 21% patients had history of atopy and 8% had abnormal thyroid function tests. Causative factors noticed in 46% patients and remaining were idiopathic (54%). Infections (32.6%) constituted the major etiological factor followed by physical urticaria (30.4%), food (23.9%), medication (11%) and inhalants (2.1%). In infective agents, 46.6% were bacterial followed by helminthic (33.3%). In 29.6% of CIU patients, the ASST was positive indicating auto-immune urticaria.</p><p class="abstract"><strong>Conclusions:</strong> The etiology cannot be identified in most number of patients and hence they were labelled as CIU and the common causative agents observed were infections followed by physical urticaria, food and medication. ASST is considered as the relevant screening test to detect autoimmune urticaria.</p>

Skin writometer: A novel instrument for assessing provocation threshold in patients with symptomatic dermographism

Symptomatic dermographism, a type of physical urticaria is a common condition affecting patient’s quality of life. For its diagnosis, clinicians in India currently use tip of the ball point pen for estimating the provocation threshold. However, because of single tip of fixed length, ball point pen can-not differentiate between different grades of symptomatic dermographism. With variations in the intensity of stroke, there is a possibility of even missing the diagnosis. Hence, there is a need of a better method to diagnose symptomatic dermographism and determine the provocation threshold. Skin writometer, a plastic instrument with three arms of varying length can be novel in this regards. This instrument is simple, user friendly, easy to use and inexpensive. It can be used for diagnosis as well as assessment of treatment response in patients with symptomatic dermographism.

CME suggestions for pediatricians, allergists, and dermatologists, directed by an online survey on urticaria knowledge

Background: The Mexican Guidelines for the diagnosis and treatment of urticaria have been published. Just before their launch, physicians’ knowledge was explored relating to key issues of the guidelines. Objective: The aim of this study was to investigate the opinion of medical specialists concern-ing urticaria management.Methods: A SurveyMonkey® survey was sent out to board-certified physicians of three medical specialties treating urticaria. Replies were analyzed per specialty against the evidence-based recommendations. Results: Sixty-five allergists (ALLERG), 24 dermatologists (DERM), and 120 pediatricians (PED) sent their replies. As for diagnosis: ALERG 42% and PED 76% believe cutaneous mastocytosis, urticarial vasculitis, and hereditary angioedema are forms of urticaria, versus DERM 29% (P < 0.005). Most of the specialties find that the clinical history and physical examination are enough to diagnose acute urticaria, except DERM 45% (P < 0.01). DERM 45% believe laboratory-tests are necessary, as opposed to <15% ALLERG–PED (P < 0.005). However, PED 69% did not know that the most frequent cause of acute urticaria in children is infections, versus ALLERG– DERM 30% (P < 0.005). Many erroneously do laboratory testing in physical urticaria and ALLERG 51%, DERM 59%, and PED 37% do extensive laboratory testing in chronic spontaneous urticaria (CSU); many more PED 59% take Immunoglobulin G (IgG) against foods (P < 0.005). More than half of non-allergists do not know about autologous serum testing nor autoimmunity (P < 0.05). As for treatment, there were a few major gaps: when CSU was controlled, >75% prescribed antihistamines pro re nata, and >85% gave first-generation antiH1 for insomnia. Finally, >40% of DERM did not know that cyclosporine A, omalizumab, or other immunosuppressants could be used in recalcitrant cases. Conclusion: Specialty-specific continuous medical education might enhance urticaria management.

Urticaria

Urticaria is an inflammatory complaint characterized by short-lived skin swellings termed ‘wheals’ or ‘hives’. It can be divided into acute urticaria, where the disease has an abrupt onset, and chronic urticaria, where wheals have occurred on a regular basis for over 6 weeks. Physical urticaria is a subgroup of chronic urticaria where an underlying external/physical trigger can be identified, while contact urticaria arises from contact with a chemical substance on the skin or mucous membranes. Angiooedema represents a similar process affecting the deeper dermal tissue and has a predilection for the skin around the eyes and mouth. It may occur in association with urticaria or as an isolated complaint.

Autologous Serum Skin Test for Initial Identification of Auto- Antibodies in Chronic Urticaria

Background: Autologous serum skin test (ASST) is easy to perform, cost effective measure for initial identification of auto-antibody in patients suffering from chronic urticaria which may occur due to autoimmune trigger by spontaneously developed auto-antibodies against FcμRI receptor of skin mast cells.Objective: This review is designed to see the positivity of ASST in patients suffering from chronic urticaria.Materials & Methods: This a retrospective data analysis conducted from the records of patients suffered from at least two episodes of urticaria or more in a week for 6 weeks and who did ASST aged more than 10 years between July 2015 to June 2017. These subjects were not pregnant or lactating mother, did not had urticarial vasculitis, predominant co-existing physical urticaria and had negative Hepatitis B antigen and anti-nuclear antibody reports.Results: Total 53 were included in this study of them 33 were female. Mean age was 32 years with a standard deviation (SD) of 11 years. Among study patients 16 (30.2% of total) had a positive ASST result. No age or sex difference was observed in positive ASST cases. In positive cases significant (p-value:<0.001) mean induration difference of 2.75mm with a SD of 1.00 mm observed than induration produced by negative control.Conclusion: ASST is easy and effective tool for initial identification of auto-reactive urticaria.J MEDICINE JUL 2018; 19 (2) : 100-103