Acute urticaria is common in adults and children and can be caused by eating some medicines or food or due to an infection in the body.
In acute urticaria, the duration of the disease is 6 weeks or less, and mostly recovery is achieved within 2 to 3 weeks, and its treatment is with antihistamines and in some cases with corticosteroids.
In general, acute urticaria affects 12 to 22% of the general population during their lifetime.
And in younger children, the acute form of urticaria is more common than chronic urticaria. It can affect all age groups, from a 3-month-old infant to an 88-year-old person. Its average age is early twenties.
In younger children, it is seen equally in boys and girls, but in adults, it is more common in women (60% of cases).
The cause of acute urticaria is unknown in 30 to 50% of cases (most cases) in children, respiratory infections or infections of other parts of the body are the most important irritants of acute hives, where it is difficult to diagnose the cause of acute hives because it is possible It may be caused by an infection or due to the medicine that is used after the infection. In some cases, we also have intraoedema after urticaria, especially after drug urticaria that occurs in the hospital.
In general, infections such as viruses (adenovirus, enterovirus, influenza virus and rotavirus), bacteria (Streptococcus group A, Haemophilus influenzae and Staphylococcus aureus) and parasites (Blastocytosis hominis, malaria and gall) can cause acute urticaria. .
In general, drugs were found to be the cause in 9-27% of acute urticaria cases, and 147 drugs were reported in this study, the most important of which are antibiotics and non-steroidal anti-inflammatory compounds (NSAIDS).
Also, cross-reaction between one class of cephalosporins and another class of the same group may be seen, or cross-reaction may not be seen between two classes of the same group.
Among the most important drugs that cause acute urticaria are ACE inhibitors, antibiotics (especially cephalosporins and penicillins), antihistamines, aspirin and NSAIDS, blood products, IVIg and oral methylprednisolone.
In recent studies, foods were found to cause acute urticaria less than infections and drugs. Among the foods that cause acute urticaria, we can mention cow’s milk, eggs, fish, tomatoes, kiwi and wheat flour, and acute urticaria rarely occurs in systemic diseases. The sentence SLE or lupus is seen.
The main point of acute urticaria, which distinguishes it from other diseases, is the following factors, including its temporary nature, which lasts less than 24 hours, and the fact that blisters, peeling, or traces of the lesion are not visible, these are the distinguishing features of acute urticaria. It is similar to other diseases.
Erythema multiform
Sometimes acute urticaria lesions like erythema multiforme lesions are circular lesions with a pale center, which in erythema multiforme the center of the lesion gradually blisters and the lesion remains for a long time, while in acute urticaria In less than 24 hours, the lesion will disappear and may appear elsewhere.
Erythema Toxicum
This lesion is actually the same as baby acne, which are usually similar lesions and remain fixed for a few days, unlike acute hives, which resolves in less than 24 hours.
Atopic eczema (Atopic eczema or contact dermatitis),
the lesions here are also swollen and red, but in atopy, there are changes in the epidermis, including peeling, and the lesions remain for several days.
Polymorphic Eruption of Pregnancy
lesions in this disease are seen in the abdominal area, especially in areas under pressure, which remain for a long time.
Cellulitis
The lesions in cellulitis are unilateral, permanent and painful, and are usually large and at the same time the patient is feverish and uncomfortable.
Progesterone induced dermatosis
here, the hives are repeated every month before the menstrual cycle, which is different from acute hives.
Urticarial vasculitis,
urticarial lesions in this disease remain for a long time and the lesions become bruised, and at the same time, the person has systemic symptoms, where a skin biopsy is helpful. vessel, neutrophil infiltration and fibronoid necrosis are observed.
Lupus SLE disease
In lupus, urticarial or pseudo-urticarial lesions may be seen.
Physical urticaria and cholinergic urticaria are very common and chronic diseases and cause disability to the patient.
The treatment of choice in this type of urticaria is to refrain from contact with the irritant and its initiator, and the second line of treatment will be the use of non-sleeping second generation antihistamines (H1 blockers), which are effective in physical and cholinergic urticaria. to be
Physical urticaria is defined by itchy swelling and redness and inflammation of the skin and by the appearance of angioedema caused by a physical agent.
Physical factors include mechanical factors (friction, pressure and vibration), thermal factors (cold or heat) and electromagnetic radiation (sunlight radiation).
Cholinergic urticaria is an urticaria that occurs due to stimulation, but it is not classified as physical urticaria because its symptoms arise in response to an increase in body temperature. Signs and symptoms of cholinergic urticaria begin with exercise and hot showers. But physical factors (pressure, impact and cold) cannot cause this type of hives.
Chronic idiopathic urticaria is a common disease. Recently, evidence has been presented to suggest that at least some of these patients have an autoimmune origin. The result of a study has shown that there is a very strong relationship between chronic urticaria and autoimmune diseases, in these patients hypothyroidism and hyperthyroidism and autoantibodies are present.
It has been seen in women with chronic urticaria that they had a high incidence of rheumatoid arthritis, Sjogren’s syndrome, celiac disease, type I diabetes and systemic lupus erythematosus (SLE) during ten years of follow-up after the diagnosis of chronic urticaria.
A common pathogenic mechanism has been described in chronic urticaria patients with the presence of autoantibodies and the presence of a chronic inflammatory process associated with high mean platelet volume (MPV).
In another study, the relationship between menstruation and chronic urticaria has been investigated and it has been seen that there is an important relationship between chronic urticaria and menstruation and its feature is related to the role of basophils in this regard.
In general, physical and cholinergic urticaria are chronic diseases that include 25% and 5% of chronic urticaria patients, respectively.
This type of hives is more common in young people.
Dermographism urticaria is the most common type of physical urticaria (about 50% of cases) and has a prevalence of 5% in the general population.
Dermographism, which means writing on the skin, is a disease that occurs with itching and a burning sensation on the skin and a linear bump with erythema due to scratching on the skin, and in most patients, it remains in that area for 1.5 to 2 hours.
The symptoms of this type of hives can disrupt people’s lives.
According to published articles, the average duration of the disease is 6.5 years.
Delayed pressure urticaria is characterized by swelling similar to erythematous angioedema.
This type of hives is the only hives in which we do not see the peripheral protrusion of the skin lesion (wheal).
This swelling occurs in areas of the skin where pressure has been applied. Swelling occurs due to vertical pressure and can be accompanied by itching, burning or pain. Flu-like symptoms, arthralgia or lethargy and weakness can occur in this type of hives.
Certain situations cause this type of hives, such as carrying a bag with a belt that puts pressure on the shoulder, or walking in shoes that are tight, or standing with your feet on the step of a ladder without shoes and sitting on a chair that has a mattress. does not have
Swelling occurs after 4 to 8 hours of pressure and remains in place for hours (up to 24 hours in some patients).
The average duration of delayed pressure urticaria varies from 6 to 9 years in different people.
Many patients with this type of urticaria can also have spontaneous chronic urticaria or suffer from other types of physical urticaria.
In one third of patients with chronic spontaneous urticaria, we can see the exacerbation of hives in the areas of the skin where pressure has been applied.
In these patients, the important point, but sometimes it is difficult to prove this issue, is to determine whether they have delayed pressure urticaria and spontaneous chronic urticaria at the same time, or whether their disease is chronic spontaneous urticaria that has recurred due to pressure.
In this regard, it is important to know that in spontaneous chronic urticaria, the duration of urticaria is shorter than in delayed pressure urticaria, and the lesion is much more superficial than the swelling that is similar to angioedema seen in delayed pressure urticaria. .
Physical urticaria, which has a specific physical cause and is the most frequent, bothers the affected person for several years (6-7 years on average) and causes a decrease in the health-related quality of life. Physical urticaria is very serious and sometimes difficult treatments cannot be handled, but it is not taken seriously by doctors, just because the cause is known, unfortunately, it affects mostly young people between 20 and 30 years old. It can be and there are different types of which dermographism is the most common model, nearly half of the physical cases are caused by vertical pressure or rubbing or vibration.
It is a chronic urticaria which is more common in women, it is also painful and it stays in one skin area for more than two days and then it leaves a brown residue like dead blood, it can also be seen with punctate purpura and targella and along with systemic symptoms of fever. Weight loss has joint pain, enlarged lymph nodes, and bone pain.
Sometimes it is limited to the skin or with the involvement of other organs of the body, which occurs in the thyroid-celiac or in the form of lupus or Sjogren’s, reduction of complement and positivity of autoimmune factors, hematuria, protein, urea, eye involvement, digestive nerves and positivity of Raynaud’s phenomenon (bruising) The thumb in the cold)
urticaria and scolitis need corten, and with its reduction, the urticaria recur. Autoantibody tests such as double-stranded NA and rheumatoid factor are positive.
It is diagnosed by taking a sample (biopsy) of the skin. In its treatment, non-steroid pain relievers, total shisin pulse, dexamethasone and many other non-conventional drugs play a role.
Infiltration of mastocytosis, which is the accumulation of mast cells in a maculopapular form, and it has types that if it is in one area of the skin, it is a focal-mastocytoma (especially for infants under 6 months), and if the lesions are spread on the skin, it is called cutaneous mastocytosis, which is either diffuse or the main case is urticaria. It is pigmentosa (molifocal), if we apply a little pressure or heat near the lesion, new hives will be formed (you have symptoms). If infiltration occurs in the blood and other organs, it is called systemic mastocytosis, and in some cases, it is considered malignant. It is not hereditary and is rarely associated with telangiectasia, which is specific to adults.
Flushing, itching and fatigue, abdominal pain (more than all other urticaria), chronic diarrhea, bone and muscle pain, hypotension, and syncope can also be seen. The macule and papule lesions are brown in color, which are more in the covered areas of the body, and the head- The face, palms, and feet are not involved, and the skin type is more common in children and they get better until puberty. Trauma (do not put pressure on the lesions because it causes low blood pressure and syncope), mental and emotional stress, any type of infection, even vaccination and unconsciousness.
But in adults, it appears in the third and fourth decades and becomes a systemic form, even if the skin lesions subside and there is malignancy (leukemia or mast cell sarcoma), which has a bad prognosis.
The interest of mastocytosis in all types of anaphylaxis, whether with bees or unknown, is so high that it is recommended to inject epinephrine with them.
Providing reassurance and peace that most cases do not have an important background and will be fine, and will not even require heavy tests or heavy food abstinence, and there will be no need to self-inject epinephrine because the diagnosis of anaphylaxis is other than hives.
Avoiding and not eating medicine and food can sometimes be the only treatment, but in general, the appropriate treatment will be chosen according to the type of hives.
It is recommended to replace non-steroidal painkillers with acetaminophen-tramadol or atoricoxib, and of course, gradual desensitization with painkillers and aspirin.
Changing the antibiotic from the penicillin family to azithromycin or …
1-2% menthol lotion and calamine, which are effective in some hives by cooling the skin and are sometimes used together with other treatments.
Second generation antihistamines, either one or a combination of them, which are the first line of drug treatment, and if it does not respond to the normal amount and control is not done, the amount can be increased up to 4 times the normal amount every two weeks until two weeks in acute urticaria. And in chronic urticaria, it can be controlled for three to four months and then decrease.
To quadruple a drug or add another to it is the allergist’s preference. The best second generation drugs may not be very different, but Levocetirizine, Bilastine, or Rapatadine may be better than the others.
The first generation, which are sleep-inducing and have cholinergic side effects (dry mouth, etc.), are sometimes added to the second generation and are not completely out of circulation and are occasionally prescribed.
Cimetidine- Rainatadine, Fomatodine, etc. (H2 blocker) which used to be added to H1 blocker antihistamines are no longer recommended unless the patient has a stomach problem or the corten does not irritate the stomach.
Antileukotriene combined with a new antihistamine which is a kind of second line treatment and requires the preference of both the doctor and the patient and in cases of positive intradermal test of the patient’s serum or urticaria from the aspirin family or some foods give better results, but menotherapy ( monotherapy) with antileukotrienes is prohibited in urticaria.
The third line of short-term treatment is thirty milligrams of prednisolone (or equivalent to half a milligram per kilogram of body weight in children) for three to five days.
Urticaria occurs acutely and chronically at different times, including during pregnancy. Certain dermatoses sometimes occur during pregnancy. It is sometimes said that pregnant women have more male fetuses, although it is not accepted by everyone, but there is no special hives during pregnancy. Although the prevalence of angioedema type 3 can increase during pregnancy due to hormones, and a type of autoimmune dermatitis caused by progesterone also occurs.
Viruses and allergic reactions to food and drugs and contact with chemicals and physical stimuli are among the causes of hives, although in most cases the cause of hives cannot be found, which is called idiopathic hives. Chronic hives in severe cases are very problematic and cause It is determined only in 20% of cases. In addition to itching, hives also have a temporary and transient red skin lesion. In some cases, deep involvement of the skin and subcutaneous tissue causes skin-mucous symptoms or angioedema.
To help diagnose patients, they can take pictures of their skin lesions at different times and have the pictures. During pregnancy, hormones have certain changes. HCG increases and reaches a maximum after 2-3 months and then plateaus.
Inhibin and relaxin hormones reduce uterine contractions.
There is no direct connection between pregnancy and hives. Pregnancy does not have an increasing effect on hives, nor does hives affect fertility and is not a teratogen, although in one case, a woman had hives during two consecutive pregnancies, and this person also had a skin reaction to estradiol skin injection. In non-pregnant and pregnant people with urticaria, the blood level of dihydroepiandrosterone is lower, which prevents the production of Th2 cytokines.
The prevalence of hives in pregnancy is not more than in other people. The cause of acute urticaria in 50% of cases is food, medicine, infections and bites.
Sometimes it is necessary to inject epinephrine, steroid and antihistamine. In pregnant women, in cases of anaphylaxis, epinephrine can be injected under the supervision of a cardiologist.
Chronic urticaria can be spontaneous or autoimmune. In the autoimmune form, antibodies are produced against IgE Recp or IgE itself. The test of histamine release from basophils is positive in these people.
In pregnancy, the treatment of hives is slightly different. Based on the FDA classification, drugs used in pregnancy are divided into the following groups:
Group A: It has been proven to be safe in human and animal fetuses.
Group B: Animal embryos have not had complications with this drug, and there have been no reports of complications or insufficient studies in human embryos.
Group C: Complications have occurred in animal embryos and its risk has not been proven in humans, provided that the benefit of the drug is greater than the possible risk, the drug is taken.
Group D: It has caused complications in both animal and human embryos and is used only in special cases.
Group X: Complications have been seen in both human and animal fetuses, and it is not used in pregnant women.
The treatment of urticaria is symptomatic and the first step in the treatment is second-generation antihistamine antihistamine drugs. In some chronic forms, it is necessary to increase the dose of antihistamine.
from second generation antihistamines; Cetirizine, levocetirizine, loratadine in group B and fexoftadine, desloratadine in group C are recommended drugs in pregnancy.
of the first generation antihistamines; Chlorpheniramine, cyproheptadine are recommended from group B, and hydroxyzine, promethazine are from group C.
Second generation antihistamines are recommended in the first trimester.
Antihistamines are recommended to be stopped 3-7 days before delivery because the baby’s liver cannot metabolize these drugs. Steroids are not recommended during pregnancy, but in very severe cases, steroids can be used for 2-3 days.
Leukotriene receptor antagonists (group B) can be used except Ziloten (group C). These are secreted in breast milk. Cyclosporin is in group C drugs, but no teratogenic effect has been seen.
It is concluded that urticaria and angioedema are not complications of pregnancy, it has no special effect on pregnancy, and its treatment is not significantly different from ordinary people. Only when using drugs, one should pay attention to the FDA drug classification.
Hereditary angioedema : It is a rare disease and is autosomal dominant. The C1 inhibitor substance prevents the spontaneous activation of C1 in pathocomplement, and in case of deficiency of C1, pathocomplement is activated and C4 decreases. Recently, it has been determined that the Kalkinin-kinin system and Hageman factor and bradykinin increase is an important factor in hereditary angioedema.
Clinical symptoms : It occurs repeatedly in the form of episodes of swelling and the common areas are the skin of hands and feet, face and genitals, digestive system (diarrhea and vomiting), and larynx and blood pressure reduction. In a report of 400 patients with hereditary angioedema, urticaria was reported in only 2 cases. The prevalence of the age of onset of the disease is in the second decade, then the first decade and the third decade, and then in older ages. 70% of patients have twelve attacks per year and 30% have more than 12 angioedema attacks per year.
These attacks of angioedema can occur after trauma, pressure, emotional issues, menstruation and ovulation in women and infections.
Angiotensin converting enzyme inhibitor (ACEI) drugs can also produce angioedema in these patients. The use of these drugs is contraindicated in these patients.
Angiotensin convertase blocker drugs can increase edema. Also, in women, the use of contraceptives is involved in the exacerbation of swelling.
Tranexamic acid, a bradykinin antagonist, concentrated INH C1, and danazol are sometimes effective.
Urticaria diseases that do not cause angioedema.
Cholinergic urticaria: Cholinergic urticaria occurs when the body temperature increases due to various reasons, in situations such as exercise, hot shower, consumption of spicy and peppery foods, and alcohol consumption.
According to the new guidelines, vasculitic urticaria is not classified as urticaria due to its underlying nature. Vasculitic urticaria is a leukocytoclastic vasculitis that manifests itself as a wheal. Unlike histamine-dependent urticaria, this type of urticaria often stays in one place for more than 24 hours and causes a brown spot due to small bleedings. Sometimes a state between vasculitis and chronic urticaria occurs, which is related to an autoimmune process. Minimal changes similar to vasculitis may be seen in chronic urticaria. In a survey, among 83 patients with chronic urticaria, 10 had the histological appearance of urticarial vasculitis. Urticaria vasculitis is related to hypocomplementary and systemic disease.
The cost of care for patients with chronic urticaria includes 4 direct costs (medicines, outpatient visits, emergency department/hospital costs, and tests) and 2 indirect costs (loss of income due to outpatient visits and absence from work due to urticaria). ), is
The initial average direct cost for drugs mainly includes non-hypnotic antihistamines, but also hypnotic antihistamines, tapering corticosteroids, doxepin, self-injected epinephrine hydrochloride, histamine II blockers, and antileukotrienes, which also includes the average annual cost. Outpatient visits, emergency department visits and laboratory tests are added. The decrease in average annual income due to absenteeism and outpatient visits should also be taken into account. Among the above cases, the average annual cost of drugs has the greatest economic impact.
Because chronic urticaria is a difficult problem to treat, patients at the extreme end of the spectrum require specific treatment.
For example, in a study of IVIG, it caused a long recovery (in a 3-year follow-up of patients), in 30% of patients with chronic autoimmune recalcitrant urticaria, which has recently been confirmed by other researchers. Other approved treatments in selected patients recommended in EAACI/GALEN/EDF/WAO guidelines include cyclosporine, dapsone and omalizumab. Immunomodulatory treatments for which less evidence is available include methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide, and tacrolimus. Plasmapheresis has been successfully used in a specialized center.
Although the costs of these treatments have not been officially evaluated, they are significant.
Chronic urticaria is a dermatosis that causes problems for doctors and puts them in the face of patients who have a frustrating and unpredictable disease and their treatment is costly and time-consuming. Patients have high expectations and a severe disturbance in the quality of life, and a severe psychological burden is imposed on them.
In addition, a significant economic cost is imposed on the patient and the society due to chronic urticaria, in addition to which, intangible costs are also added to the above costs as a result of the impact of chronic urticaria on the quality of life.
Omalizumab is used in patients with chronic idiopathic or chronic spontaneous urticaria that is resistant to treatment. The urticaria activity measurement (UAS) method is used to determine the dosage and treatment of this medicine.
In each patient, a daily note is used to determine this score.
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