Urticaria - Dr Maryam K Alnajem

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1. Dermatology Case P resentation Dr . Maryam AlNajem Dermatology resident April 2017

2. HPI: Haya is a 47 years old lady, with 3 days history of widespread pruritic skin rash. Individual lesions last ≈ 8hrs . PMH: Appendectomy 3 weeks ago Allergies: unknown to have allergy Medication: Ibuprofen ( for pain post appendectomy) and aspirin Family hx : no similar condition in the family Case 1

3. On Examination: Vital sign: HR 80 BP 130/80 RR 16 O₂ sat: 98% on RA Skin examination: diffuse erythematous wheals

4. Case 2 HPI: Khalid is a 28 years old gentleman who present to the dermatology clinic with a 6 months H/O periodic swelling on his body. The swelling started with localized itching followed by raised lesions that disappear within minutes to hours . The lesions are worse with exercise, rubbing of the skin and embarrassment. Lesions appear 2-3 times / week

5. PMH: unremarkable Allergies: Unknown to have allergy Medication: Vitamin D supplement Family Hx : no similar hx in the family On Examination: Vital signs within normal limits Skin examination: almost clear no skin lesion is seen

6. Urticaria

7. Urticaria is characterized by transient skin or mucosal swellings due to plasma leakage. Superficial dermal swellings are wheals. Deep swellings of the skin or mucosa are termed angioedema . Wheals are characteristically pruritic and pink or pale in the center, whereas angioedema is often painful, less well defined and shows no color change .

8. There are several recognizable clinical patterns of urticaria and different causes: allergy autoimmunity drugs dietary pseudoallergens and infections. Many cases remain unexplained (idiopathic) even after an extensive evaluation. C1 esterase inhibitor deficiency needs to be considered as a cause of recurrent angioedema without wheals.

9. INDIVIDUAL WHEALS LAST NO MORE THAN 24 HRS URTICARIA VASCULITIS ˃ 24 HRS

10. Angioedema is painful rather than red and itchy, and often last for 2 to 3 days

11. Clinical features

12. How to approach to urticaria patient

13. 1. Time of onset of disease 2. Frequency/duration of and provoking factors for wheals 3. Shape, size, and distribution of wheals 4. Associated angioedema 5. Associated subjective symptoms of lesions, for example itch, pain 6. Family and personal history regarding urticaria , atopy H istory

14. 7. Previous or current allergies, infections, internal diseases, or other possible causes 8. Surgical implantations and events during surgery, for example after local anesthesia 9. Use of drugs (e.g. NSAIDs), injections, immunizations, hormones, laxatives, suppositories, ear and eye drops, and alternative remedies) 10. Observed correlation to food 11. Relationship to the menstrual cycle

15. 12. Smoking habits (especially use of perfumed tobacco products or cannabis) 13. Type of work 14. Hobbies 15. Quality of life related to urticaria and emotional impact 16. Previous therapy and response to therapy

16. generalized allergic reaction? Chest tightness or difficulty breathing Hoarse voice or throat tightness Nausea, vomiting, or cramping abdominal pain Sign and symptoms to suggest underlying systemic disorder? Unexplained fever Weight loss Arthralgia Red flag

17. Physical examination Vital signs Urticarial lesions may or may not seen

18. Investigations Laboratory studies CBC with differential Urinalysis ESR TSH ( CU) Tests for allergic causes → if hx reveals specific trigger Skin biopsy

19. T reatment

20. Antihistamine Reduce pruritus Flatten wheals Shorten wheal duration Reduce wheal number Should be taken on a daily basis 1 st generation (Classic) antihistamine Vs. 2 nd generation antihistamine Combination drugs from different groups can lead to better control of urticaria

21. 1 st generation antihistamine Problematic because sedation and anticholinergic side effect Chlorpheniramine ( 4 mg TDS) is ttt of choice for pregnant women 2 nd generation antihistamine Well tolerated OD, but can be taken up to 4X e.g. fexofenadine ( 180 mg ), loratidine (10 mg), cetirizine (10 mg)

22. Prednisone/ prednisolone Effective High dose (50-30 mg OD) to achieve good initial control for severe urticaria Additive therapy but not alternative Regular ttt should be avoided b/c of usually prolong duration of CU and b/c their SE Epinephrine SC or IM injection Ttt of choice for anaphylactic shock or anaphylactic reaction

23. Omalizumab ( Xolair ) A monoclonal antibody against IgE , was approved for CU refractory to H1 antihistamines by the FDA in 2014 Safe and effective Very costly Requires regular visits to a clinic for administration 150 mg or 300 mg every four weeks No specific laboratory monitoring is required for patients receiving omalizumab for CU

24. Thank you