Diagnosis and treatment of physical urticaria Presented by Theerapan Songnuy, MD. Dec7, 2012

1. Physical Urticaria
Theerapan Songnuy
Dec 7, 2012

2. Overview
• Definition
• Epidemiology
• Classification
• Diagnosis
• Treatment

3. Urticaria
Urticaria :
- The appearance of pruritic,erythematous
skin elevation which blanch with pressure
- Small venules & capillaries dilation in
superficial dermis
- Collagen fiber swelling
Angioedema :
- similar pathologic reaction
- Involves deep dermis & subcutaneous tissue
- Fewer mast cell & sensory nerve ending
- More painful or burning sensation than pruritus
- Often on face, tongue ,genitalia & extremities
Middleton’s Allergy 7th Edition

4. Physical Urticaria
• A heterogeneous group of inducible conditions
that includes:
- Symptomatic dermographism/urticaria
factitia
- Cold contact urticaria
- Heat contact urticaria
- Delayed pressure urticaria
- Vibratory urticaria /angioedema
- Solar urticarias
- Aquagenic urticaria
- Contact urticaria
- Exercise induced urticaria /anaphylaxis
Allergy 2009; 64 (12): 1715-1721

5. Physical Triggers
• Symptomatic dermographism / Urticaria factitia : mechanical
stroking
• Cold contact urticaria : skin contact with cold air/water/solids
• Heat contact urticaria : skin contact with hot air/water/solids
• Delayed pressure urticaria: vertical sustained pressure
• Vibratory urticaria/angioedema : vibration (e.g. pneumatic
hammer)
• Solar urticaria : UV and/or visible light
• Aquagenic urticaria : water contact at any temperature
• Contact urticaria : contact with an allergic or nonallergic
stimulus
• Exercise induced urticaria /anaphylaxis : physical exercise
• Cholinergic urticaria : increased core body temperature
Allergy 2009; 64 (12): 1715-1721

6. Epidemiology
• Urticaria
- The life-time prevalence of any subtype is 20%
• Physical urticaria
- prevalence 20% of chronic urticaria
- In children prevalence ranges from 6.2-25.5%
Allergy 2009;64: 1417-1426
Ann Allergy 1993:71:205-12
Ann Allergy 1992; 69: 61-65

8. Aim: To study the prevalence, type, clinical data &
natural history of physical urticaria including
prognostic factors for remission
Material & Methods :
- A retrospective study
- The Dermatologic Unit, Siriraj Hospital
- Jan 2003-Dec 2008
- Patients aged above 18 years
- Demographic data, causes of
urticaria, associated diseases, physical
exammination, lab etc.
JEADV 2011 ; 25: 1194-1199.

9. • Tests to categorize type
- Dermographometer ( pressure at 4900 g/cm2 )
- Delayed-pressure ( sandbags 15 lbs over one
shoulder for 15 min) then observe 2-8 hr. later
- Cold urticaria ( Ice-cube test, place ice inside plastic bag on
forearm 10 min then observe 15 min later
- Cholinergic ( run until exhausted & sweaty ) then
observe within 15 min
- Adrenergic ( ID noradrenalin 3-10 ng in 0.02 ml saline
observe erythematous papule & halo )
JEADV 2011 ; 25: 1194-1199.

10. • Tests to categorize type
- Solar urticaria ( photo test with visible light
UVA, UVB )
- Others ; CBC, UA, ESR, ANA, cryoglobulin
HBsAg, anti-HCV Ab etc.
Remission: non-urticarial wheal for at least 6
months after stop medication & negative test
JEADV 2011 ; 25: 1194-1199

11. JEADV 2011 ; 25: 1194-1199

12. JEADV 2011 ; 25: 1194-1199

13. JEADV 2011 ; 25: 1194-1199

14. JEADV 2011 ; 25: 1194-1199

15. • From chronic urticaria: physical urticaria was 7.2%
• The most common type is symptomatic dermographism
• Only 13.9% associated with chronic spontaneous urticaria
• No multiple types of physical urticaria
• ESR was the most common abnormal labs
• The median time after onset before 50% remission
- Cholinergic urticaria took the shortest course
- Delayed-pressure took the longest period
- After 1 y & 5 y from onset of symptom, 13 % & 50%
of physical urticaria were free of symptoms

16. Symptomatic Dermatographism
• Syn : urticaria factitia, dermographic urticaria
• The most common subtype of physical urticaria
• Has to be differentiated from simple
Dermographism where wealing, but not
pruritus, occurs after moderate stroking of the
skin
• Develope itching & wealing at a lower force
than that required to induce simple
dermographism
• Other types of dermographism such as white
dermographism (in atopic patients) are
unrelated to symptomatic dermographism
Immunol Allergy Clin North Am2004;24:225–246.

17. Symptomatic Dermatographism
• Provocation testing
- A dermographometer : to apply a rubbing stimulus to a subject’s skin
using predefined and reproducible pressures
- A calibrated dermographometer is commercially available (HTZ
Limited, Vulcan Way, New Addington, Croydon, Surrey, UK)
- It has a spring-loaded smooth steel tip 0.9 mm in diameter. The
pressure on the tip can be varied by turning a screw at the top of the
instrument.
- The scale settings from 0 to 15 ( tip pressures from 20 to 160 g/mm2 )
Immunol Allergy Clin North Am2004;24:225–246.

18. Figure 3 Dermatographism. Linear stroking of skin
elicits a wheal within several minutes.
The American Journal of Medicine 2008; 121 ( 5) : 379 - 384

19. Symptomatic Dermatographism
• Diagnosis of symptomatic dermographism
-the smooth blunt object should be held
perpendicular to and used to apply a light
stroking pressure to the skin of the upper back
or volar forearm
- The skin at the test site should be unbroken
and free of obvious signs of infection
-Three parallel lines (up to 10 cm long)
should be made with dermographometer
settings equivalent to 20, 36 and 60 g/mm2.
Immunol Allergy Clin North Am2004;24:225–246.

20. Symptomatic Dermatographism
• The positive reaction : showing a wheal
response & report pruritus at the site of
provocation at 36 g/mm2 (353 kPa) or less
• A wheal response without itch on provocation
at 60 g/mm2 (589 kPa) or higher indicates
simple dermographism
• The test response should be read 10 min after
testing
J Am Acad Dermatol2008;59:752–757.

21. Management of Symptomatic
Dermatographism
• Diphenhydramine or hydroxyzine 25-50
mg. qid for severe patient
• Non-sedating antihistamine in mildly to
moderately severe cases, can be triple
the usual dose
Middleton’s Allergy 7TH Edition

24. Conclusion
• Cyclosporin may be worth trying for
antihistamine-resistant DU, especially in
those patient cases characterized by
severe itching
. Further studies on a larger scale are
expected to be conducted in order to
generate stronger levels of clinical
evidence.

25. Cold Urticaria & Related
Disorders
• Trigger by a cold stimulus ; wind, liquid
holding cold objects
• Total body exposure can lead to hypotension
( swimming)
• Disease begin in any age group, young adult
• “Ice-cube Test” placing a plastic containing ice
cube inside on patient’s forearm for 4 min, then
observe 10 min
Middleton’s Allergy 7th Edition

26. Cold Urticaria
• Positive : a palpable & clearly visible weal & flare reaction
with itchy and/or burning sensation
• In a positive test reaction, threshold testing should be
performed
• Threshold level may help patients to avoid risky situations and
their physician to optimize treatment
• Determining the stimulation time threshold, which is the
shortest duration of cold exposure required to induce a
positive test reaction
• Temperature thresholds, i.e. the highest temperature sufficient
to induce a positive test reaction, can be assessed with
TempTest
J Allergy Clin Immunol1986;78:417–423.

27. Cold-Dependent Syndromes
• Idiopathic cold urticaria
• Systemic cold urticaria( ice cube test negative) sensitive
to cold air
• Cold-induced cholinergic urticaria
• Cold-dependent dermographism
• Delayed cold urticaria ( edema, pain)
• Localized cold urticaria ( previous insect stinging)
• Cold reflex urticaria
• Associated with abnormal serum protein
- cryoglobulinemia
- cold agglutinin disease
- cryofibrinogenemia
- paroxysmal cold hemoglobinuria
Middleton’s Allergy 7th Edition

28. Cold Urticaria
• Mediators releasing from mast cell
- histamine
- PAF
- LTE2
- Prostaglandin D2
- TNF-alpha
- IL-3
Middleton’s Allergy 7th Edition

29. Management of Cold Urticaria
• Avoidance
• Cyproheptadine is the drug of choice
• Non-sedating H1 antihistamine
• For patient where IgE has a
role, monoclonal IgG anti-IgE may be
effective
Middleton’s Allergy 7th Edition

30. Atopic dermatitis and skin disease
High-dose desloratadine decreases wheal
volume and improves cold provocation
thresholds compared with standard-dose
treatment in patients with acquired cold
urticaria
: A randomized, placebo-controlled, crossover
study
Frank Siebenhaar, MD, Franziska Degener, MD,Torsten
Zuberbier, MD, Peter Martus, PhD,andMarcus Maurer, MD
Berlin, Germany
J Allergy Clin Immunol 2009;123:672-9

31. - Aim: assess the effects of 5 and 20 mg of
desloratadine and placebo on cold-induced
urticarial reactions in patients with acquired
cold urticaria (safety & efficacy)
- A prospective, double-
blind, randomized, placebo-controlled
crossover study
J Allergy Clin Immunol 2009;123:672-9

32. • Materials & Methods
- OPD of urticaria specialty clinic of the Allergie-
Centrum-Charite´ of the Charite´-
Universita¨tsmedizin, Berlin, Germany
- Patients aged 18 to 75 years with a confirmed
diagnosis of Acquired Cold Urticaria , made at least
6 week before
- Signs/symptoms were assessed by using the
Acquired Cold Urticaria Severity Index (ACUSI), &
triggering stimuli, previous medication use, and
concomitant disease
J Allergy Clin Immunol 2009;123:672-9

33. J Allergy Clin Immunol 2009;123:672-9

34. J Allergy Clin Immunol 2009;123:672-9

35. J Allergy Clin Immunol 2009;123:672-9

36. J Allergy Clin Immunol 2009;123:672-9

37. B, Example of thermographic images of the cold-induced wheal response over
20 minutes in a patient with ACU treated with placebo, 5 mg/d and 20 mg/d
desloratadine for 7 days
J Allergy Clin Immunol 2009;123:672-9

38. J Allergy Clin Immunol 2009;123:672-9

39. J Allergy Clin Immunol 2009;123:672-9

40. J Allergy Clin Immunol 2009;123:672-9

41. J Allergy Clin Immunol 2009;123:672-9

42. Conclusion
Treatment with desloratadine at doses of
5 and 20 mg daily significantly
decreased wheal volume/size
, improved CTTs & CSTTs in patients with
ACU
Treatment with the higher dose of
desloratadine yields higher outcomes in
wheal volume and CTTs and CSTTs
comparing with standard-dose
desloratadine

43. Solar Urticaria Treated With
Intravenous Immunoglobulins
HenriAdamski,MD, Christophe Bedane, MD, Annie
Bonnevalle, MD, Pierre Thomas, MD, Jean-Louis Peyron, MD, Bernard
Rouchouse, MD, Frederic Cambazard, MD, Michel
Jeanmougin, MD,and Manuelle Viguier, MD
Rennes, Limoges, Lille, Montpellier, Saint-Etienne, and Paris, France
J Am Acad Dermatol 2011;65:336-40

44. Solar urticaria treated with
intravenous immunoglobulins
• To report the effectiveness of intravenous immunoglobulins
(IVIG) in severe solar urticaria ( SU)
• A retrospective multicentric study via the mailing of a
questionnaire to the French Photodermatology Units
• Severe SU was defined as having a poor response to
antihistamine use and impairment of the quality of life
(impact on daily and professional life)
• Collected age, sex, medical history, medications, clinical
features, pho-tobiological characteristics, laboratory
investiga-tions, and clinical response to IVIG
J Am Acad Dermatol 2011;65:336-40

45. Table 1 Characteristics of patients before receiving IVIG
J Am Acad Dermatol 2011;65:336-40

46. Table 1 Characteristics of patients
before receiving IVIG
J Am Acad Dermatol 2011;65:336-40

47. J Am Acad Dermatol 2011;65:336-40

48. J Am Acad Dermatol 2011;65:336-40

49. Solar Urticaria
- A rare idiopathic photodermatosis
- Sun avoidance and antihistamine
- Severe solar urticaria needs more modality
such as
intravenous immunoglonulins
- Further trials are needed

50. Thank You Very Much