URTICARIA

Urticaria (1) :
• Urtica
• Transient edema in the upper dermis
• Transient leakage of plasma

Angioedema(1) :
• Edema in the upper/lower dermis and/or
subcutis
Four stages in the management of
urticaria

• Knowing the tipology of urticaria

• Knowing the causative factors
• Knowing the risk factors and some factors that
influence the uricaria
• Treatment and counceling stage
Tipology, causative factors and factors
that influence the urticaria (2)

Classifications Type
Physical (inducible)
urticarial
Ordinary urticaria Acute and chronic
Chronic: Autoimmune,
spontaneous
Vasculitis urticaria
Angioedema without Def. C1 inh,
urtica Normal C1 inh
Contact urticaria
Frequency of the type of urticaria (3)

Type % ase

Ordinary urticaria 60

Physical urticaria 35

Vasculitis Urticaria 5
 Simple clinical diagnosis of urticaria
Onset Duration Urticaria
10 mnt. after < 1 hour Physical urticaria
stimulation
> 1 hour after > 1 day Delayed pressure
continously pressure urticaria
10-30 mnt exposed > 2 hours Contact urticaria
to contactant
2 -24 hours Ordinary urticaria
1 – 7 days Vasculitis urticaria
 Urticaria and/or Angioedema
H
Recurrent unexplained fever? ACE-inhibitor treatment? i
Joint/bone pain? Malaise?? s
t
o
AID? Average urtica duration > 24 hours? HAE or AAE? Remission after stop? r
y

D
Sgni of vasculitis in biopsy? Are symptoms inducible? i
a
g
n
o
Provocation test s
t
i
c
t
Acquired/ Urticarial Chronic Chronic HAE I-III ACE-inhibitor e
Hereditary AID vasculitis Spontaneous Inducible AAE Induced AE s
Urticaria Urticaria t

T
r
Anti IL-1 AH AH Icatibant e
Effective? Effective? Effective? Effective? a
t
m
e
Omalizumab effective? n
t

Interleukin-1 Histamine & other mast cell mediators Bradykinin

 PhysicaL (inducible)urticaria
Type
Dermographism
Pressure urticarial
Vibratory angioedema
Cold urticarial
Cholinergic urticarial
Local heat urticarial
Solar urticarial
Exercise-induced anaphylaxis
Adrenergic urticarial
Aquagenic urticaria
Characteristic
Rapidly appear, fades < 30 minutes
Appear 3-6 hrs, last 24-48 hrs
Acquired idiopathic disorders
Most are autosomal dominant // facial flushing
Appear within minutes after ice cube (thermoelectric
elements) test
Appear after increase in core body, tiny pruritic urticarial.
Test methacholine Chloride i.c.
Acqired: Appear within minutes after locally applied heat
Familial: appear 1-2 hrs after challenge,lasted >10 hrs
Appear within minutes after expose to sun/artificial light
source. Irradiated (UVA/B/Visible light) – antigen on the
skin – appropriate wave length – complement activation
Most are elicited by food within 5 hrs of excercise
Develop during emotional stress or norepinephrine i.c.
Water contact to the skin
Ordinary urticaria
Acute: if lasts < 6 weeks, most are adverse reaction
Chronic: CAU & CIU (CSU)
• CAU // Hashimoto thyroiditis (Antimicrosomal
& anthyroglobulin antibodies
• CIU (CSU): recurrent urtica/angioedema without
specific triggers for > 6 weeks
Urticaria guideline recommended diagnostic test
Diagnostic test
Routine Extended
Spontaneous • Diff telling • Infectious diseases
• ESR/CRP • Type 1 allergy (Prick, RAST)
• Omission of suspected drug • Autoantibody (TA/TFT, ASST)
CSU • Pseudoallergen
• Tryptase in severe systemic dis
Inducible
CIndU
Cold Cold provocation/Threshold test Diff tell, ESR/CRP, cryoprotein
Rule out other diseases esp infections
Delayed pressure Pressure/threshold test None

Heat Heat provocation/threshold test None

Solar UV, Visible light of diff wave length and Rule out other light induced dermatoses
threshold test
Dermographic Stroking/threshold test None

Vibratory Threshold test None

Cholinergic Excersisce & hot bath provocation None

Aquagenic Wet cloth at body temp applied for 20 minut None

 Pathogenesis of urticaria (4)
Idiopathic (Spontaneous)

Immunology
• Autoimmune (autoantibody FcɛRI or IgE)
• Ig E dependent (Type I hipersensitivitas)
• Immune complex (vasculitis urticaria)
• Complement dependent (def. C1-esterase inhibitor)

Non-immunology
• The substances that have direct effect on Mast cel (opiat,
codein, radiocontras, venoms, physical stimuli, estrogen, ACTH,
Thiamin)
• Aspirin, NSAID, pseudoalergen in the food (Salisilat, azo dyes,
food preservatives)
• ACE inhibitor
Non farmacologic treatments

 Avoid the aggravating/precipatating factors (2)

 Inform how to prevent (2)

 Give symptomatic medicamentous (2)
 Consider for using NSAID (5)
 Consider for using codein, opiat (6)

 Consider for using ACE inhibitor (7)

Farmacologic treaments
First line
• Antihistamin H1
• Have sedative effects : Chlorpheniramin maleat,
Hidroksisin, diphenhidramin
• Have non sedative effects :Cetirizine, Loratadine,
Desloratadine, Fexofenadine
• Doxepin 10 mg
• Antihistamin H2
• Nifedipine
• Ketotifen fumarat
• Sodium chromoglycate
Second line
• cortikosteroid
• Stanozolol
• Sulfasalazine
• Methotrexate
Urticarial Vaskulitis
• Colchicine
• Dapsone + corticosteroid
• Indomethacine
• Hidroxychloroquine

All severe angioedem except of def. C1 ersterase inhibitor

can be given Adrenalin im/sc : 0,5 mL (pengenceran 1 :
1000) or inhalation
Third line
• Auto antibody hitamine-releasing :
• Plasmapharesis
• Cyclosporin A
• Immunoglobulin iv

Deficiency of C1-inh
Concentrate of C1 or fresh frozen plasma

Profilaksis
Steroid anabolic or plasmin inhibitor tranexamine acid
Development of treatment methode

• Imunomodulator that inhibit cytokine production

• Be careful on using of NSAID
• Downregulate production of autoimun antibodi
• Blocker of FcεRI mast cell
• Anti IgE substances