Urticaria: A Diagnostic and Therapeutic Approach American College of Physicians ACP October 10, 2008

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Urticaria: A Diagnostic and Therapeutic Approach American College of Physicians (ACP) October 10, 2008 Jill A. Poole, MD, FAAAAI, FACAAI Assistant Professor Pulmonary, Critical Care, Sleep & Allergy Section University of Nebraska Medical Center 402-559-4087 japoole@unmc.edu

Objectives To perceive the reasons for intense urticaria and angioedema To perceive the reasons for unending urticaria and angioedema To perceive the provocative difficulties for physical urticarias To examine the treatment of urticaria and angioedema

Urticaria (otherwise known as Hives) Common issue! Influences up to 20% of the populace Pruritic (tingle!) Blanche with weight Fleeting ("Leaves no follow") -No scarring

Angioedema (Swelling) Edema of the profound layers of the dermis and subcutaneous tissue. Non-setting edema Skin is not hot Non-subordinate territories It is not: "pre-tibial setting edema"

Pruritus Chronic Itch without Rash Differential conclusion is distinctive (not incessant urticaria) Uremia Cholestasis Malignancy Non-Hodgkins Lymphoma Polycythemia vera Thyrotoxicosis Multiple sclerosis Iron Deficiency Anemia Diabetes (Autonomic brokenness) Medications Psychiatric Illness

Case: 35 year old man with hives for as long as 4 days. Skin injuries are depicted as VERY irritated. Diphenhydramine helps, yet does not keep going long, and he is taking 5-6 tablets a day. Hives started when he was having supper Friday night, shrimp course. Nonetheless, he has not had any shrimp since Friday night and the hives are as yet happening. Furthermore, he has never had hives with shrimp. No swelling, shortness of breath, throat shutting, sickness, regurgitating, or loose bowels. Conclusion?

Definition: Hives enduring under 6 weeks Common triggers: Foods * Shellfish, nut, wheat, egg, crisp natural products, drain Infections More basic in youngsters Animal dander Pollens Drugs Aspirin, NSAIDS, anti-infection agents Occupational Stinging Insects Acute Urticaria Kaplan, A. P. N Engl J Med 2002;346:175-179

What do you tell the patient? It might take a few weeks for the hives to leave totally. Strict shirking of shrimp. Treatment with long-acting, non-steadying hostile to histamines. Start a research facility work up to incorporate finish blood number, finish metabolic board, thyroid testing, urinalysis. The majority of the above, aside from #4. It might take a few weeks for the hives to leave totally. Strict evasion of shrimp. Treatment with long-acting, non-quieting hostile to histamines. Start a research center work up to incorporate finish blood check, finish metabolic board, thyroid testing, urinalysis. The majority of the above, with the exception of #4.

Case: 18 year-old man with day by day hives for as far back as 2-3 months. Hives show up in the wake of scratching the skin and keep going for 30-a hour. Here and there hives happen along his abdomen when he works out. Survey of frameworks is generally negative. Conclusion?

Dermatographism A Physical Urticaria Scratching skin brings about hives enduring 30 mins to 2 hours Kaplan, A. P. N Engl J Med 2002;346:175-179

Physical Urticarias Reproducible by ecological elements Physical boosts Most every now and again in youthful grown-ups Episodic and frequently restricted to zones of actuating jolt Usually, lethargic to corticosteroids Overall, treatment with non-steadying antihistamines

Examples of Physical Urticarias 1. In the event that you stroke the skin, and a hive happens? Reply: Dermatographism 2. In the event that you put an ice 3D shape on the lower arm, and after evacuation of ice solid shape, hive happens? Reply: Cold-prompted urticaria 3. On the off chance that hives happen when the patient sweats or exposure to warm? Reply: Cholinergic urticaria or limited warmth urticaria

More Examples of Physical Urticaria 4. In the event that shoulder swells (angioedema) 4-6 hours in the wake of carrying a substantial shoulder sack? Reply: Delayed weight incited urticaria & angioedema Note: may require cortiosteroids 5. On the off chance that patient creates hives just while cutting the lawn? Reply: Vibratory-actuated urticaria

Case: 8 year old kid with various pruritic little sores on arms and legs. An insect neckline was set on Fluffy, the feline, yesterday. Papular urticaria An excessive touchiness response to the chomps of mosquitoes, bugs, kissing bugs, and different creepy crawlies causes papular urticaria. Finding? Treatment: Treat the feline

Case: 34 year-old lady with every day hives for as far back as five to six months. She sporadically has related right upper lip swelling, however denies dyspnea or throat swelling/shutting. She states hives happen haphazardly. She takes 5-6 tablets of diphenhydramine a day. Audit of frameworks is generally negative. Analysis? Etiology?

Chronic Urticaria & Angioedema Definition: Hives happening more noteworthy than 6 weeks Hives and angioedema (40%) Hives alone (40%) Angioedema alone (20%) Etiology: Difficult to decide, cause once in a while discovered Common in 3 rd and 4 th decade of life Usually not nourishments, drugs, dusts, diseases, "colors" Bad News: May a years ago… .

Chronic Urticaria & Angioedema Thyroid Disease Association Thyroid capacity tests Thyroid autoantibodies Hives: 4 to 36 hours? Immune system Autoantibodies to the high fondness IgE receptor (40%) Hives: 4 to 36 hours Idiopathic* Hives: 4 to 36 hours Urticarial Vasculitis Systemic or separated Hives: > 24 hours Faint hyperpigmentation Kaplan, A. P. N Engl J Med 2002;346:175-179

Chronic Urticaria Diagnostic Evaluation History & Physical Exam Diary Relationship of hives with menstrual cycle? Provocative tests for physical causes Laboratory tests: (Not ended up being savvy) CBC with diff, ESR, CRP, UA, LFTs Thyroid capacity, hostile to thyroid antibodies Skin tests Autologus serum skin test Complements

Chronic Urticaria Diagnostic Evaluation Skin biopsy? For the most part, not supportive Indications: Lesions enduring more than 24 to 48 hours Atypical? Scarring Red platelet extravasation Cutaneous vasculitis Urticaria pigmentosa Refractoriness to treatment

Chronic Autoimmune Urticaria Functional counter acting agent (IgG) to the alpha subunit of the high proclivity IgE receptor (30%) Functional hostile to IgE immunizer (5-10%) Diagnosis Immunoblotting has been unsuccessful Autologous serum skin testing (ASST) Intradermal infusion of subject's serum Wheal and flare response following 30 minutes Basophil CD203c Expression Greaves, JACI 2000; Kaplan, NEJM 2002

Management of Chronic Urticaria/Angioedema Avoidance or treatment of basic cause Avoidance of potentiating elements Alcohol Non-steroidal mitigating drugs Main treatment H1 against histamines Non-calming, long-acting antihistamines Combination of treatments Triple medication treatment: H1 & H2 foes in addition to leukotriene blockers Tricyclic antidepressants Immunomodulators (e.g. steroids, cyclosporine) Tried with "?" advantage: Hydroxychloroquine, dapsone, calcium channel blockers, methotrexate, colchicine, pentoxyfilline, cyclophosphamide

Urticarial Vasculitis (Rare) Inflammatory harm of vessels and postcapillary venules in the skin. Etiology: Manifestation of systemic malady Clinically: Hives holding on > 24 hours  pruritic Painful, stinging, smoldering sensation "Leaves a follow" Faint lingering hyperpigmentation, showing red platelet extravasation

Conclusions Hives Very regular Acute Urticaria (Hives < 6 weeks) History is scratch Non-calming hostile to histamines Physical Urticarias History and provocative difficulties Non-steadying histamines Chronic Urticaria (Hives > 6 weeks) Etiology: Rarely decided Therapy: Difficult