Urticaria - a Frequently Occurring Skin Disease

Urticaria is a skin disease consisting of a wheal and flare reaction. In urticaria, the localized wheal is surrounded by an area of redness that is typically itchy. In case of hives, a local increase of the permeability of the capillaries and small venules result in transient, erythematous or edematous swelling of the dermis or subcutaneous tissues. Cutaneous hives may last for 30 minutes to 24 hours.

If in an individual, the wheals or hives persist for more than 24 hours and also have joint pain and bruising, then it should be considered urticarial vasculitis.

Systemic symptoms like rhinitis, difficulty in breathing, sensation of heaviness in the chest, wheezing and abdominal pain may accompany the skin lesions and are indications for urgent treatment to avoid the complication of laryngeal edema.

Classification of Urticaria

Urticaria can be classified into acute and chronic.

Acute urticaria is usually IgE mediated. The duration is less than 6 weeks. It occurs due to various foods, drugs and infection.
Chronic urticaria lesions continue to appear in an individual for at least twice a week for more than 6 weeks due to vasculitis, physical and autoimmune causes, etc.

Provoking Causes of Urticaria

Physical factors account for 20% of cases. They are stroking (dermographism), constant pressure like prolonged sitting on a chair or tight belt, vibration like kitchen grinder or blender, cholinergic like emotion, exercise, cold and aquagenic such as urticaria after swimming.

Medications such as Aspirin, NSAIDS (nonsteroidal anti-inflammatory drugs) like Brufen (Ibuprofen), Combiflam (combination of Ibuprofen and Paracetamol), Penicillin, Codeine, Morphine, ACE inhibitors (Envas - Enalapril).

Foods and food additives can cause urticaria. For example, foods such as shellfish, eggs, nuts, strawberries, etc., and additives like tartrazine, azo dyes, hydroxyl benzoates, etc.

Inhalants such as grass pollens, animal danders, tobacco smoke and house dust.

The contact urticaria syndrome mainly due to latex, caterpillars, animals and plants.

Arthropod assaults like insect bite is the most important cause for popular urticaria.

Infections of bacteria, viral, candidial and protozoal can also be the cause.

General medical disorders such as hypo or hyperthyroidism, lymphoma, polycythemia, lupus erythematosus, pruritic urticarial papules and plaques of pregnancy.

Psychogenic causes and genetic causes like hereditary angioedema.

Investigations

In all patients a detailed history gives better yield as regards the cause than a battery of investigations. Provocative tests for physical urticarias like ice cube test for cold urticaria, exercise test for cholinergic urticaria, stroking for dermographism, etc.

In selected patients, the need will arise to check the following blood tests. Complete blood count, ESR (erythrocyte sedimentation rate), urine analysis, stool examination for ova and cyst, blood chemistry profile, ANA (antinuclear antibody), hepatitis B and C antigens and antibodies, thyroid antibodies, cryoglobulins, CH 50, hereditary C1 esterase deficiency, plasma and erythrocyte protoporphyrins (solar urticaria), skin biopsy in urticarial vasculitis and IgE and IgE receptor antibody assay.

Treatment

H1 Antihistamine is the initial line of treatment. During daytime Loratadine, Levocetirizine and Fexofenadine and at night-time Hydroxyzine or Cyproheptadine is used because of the sedation.

Corticosteroids are useful in case of acute urticaria for short duration. It is rarely used in chronic urticaria.

Mast cell stabilizers like Ketotifen 1-2 mg daily or Cromolyn sodium inhaler and Montelukast (leukotriene receptor antagonist) are useful in case of recalcitrant disease.

In case of autoimmune urticaria, Cyclosporine 2 to 2.5 mg/kg daily for two to three months or IVIG (intravenous immunoglobulin) or plasmapheresis is the treatment.

For angioedema, the treatment is same as above, along with Epinephrine 0.5 to 1 mg IM (intramuscular) in case of acute episodes and repeat every 10 to 15 minutes till remission or Ephedrine 2% aqueous spray two to three puffs for regular use in chronic cases.

Avoidance of precipitating or provoking causes is curative in case of urticaria.

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Frequently Asked Questions

1. What Are the Various Causes of Urticaria?

The following includes the list of the most common causes of an urticaria reaction:
- Foods.
- Medications.
- Infections
- Insect bites.
Internal disease.

2. How Long Does It Take for Urticaria to Go Away?

The round rashes can last for a varied amount of time in different individuals. Usually, the eruptions that are formed last only for a few minutes. Rarely, it might extend to several hours or several weeks to months. But most commonly, individuals who are affected with hives have a rash, not more than 24 hours.

3. What Are the Infections That Can Cause Urticaria?

Several infections can cause urticaria are:
- Throat infections such as streptococcus infection.
- Stomach and genitourinary tract infections.
- Fungal infections.
- Infectious mononucleosis.
- Hepatitis.

4. Which Food Should Be Avoided in Urticaria?

When you are affected by an urticaria infection, you are supposed to avoid histamine-rich foods. It includes the following:
- Cheese.
- Yogurt and other old dairy products.
- Preserved meats and bacon.
- Fruits like strawberries and cherries.
- Spinach.
- Tomatoes.
- Eggplant.
- Alcoholic beverages.
- Fermented food products such as bread.
- Fast food.

5. Is Urticaria a Serious Condition?

No, urticaria is not a severe condition. It causes difficulties like severe itching on the initial stages but resolves in most patients with proper treatment. It commonly resolves within 24 hours from the time of onset.

6. Can a Fungal Infection cause urticaria?

Urticaria can be caused by various infections that affect the human body. It also includes fungal infections. The most common fungal infection that causes urticaria is trichophyton infection.

7. What Does Urticaria Appear Like?

The urticaria rash is being termed as hives. It typically appears on the skin as reddish lesions. It might be very itchy. It can appear as elevated areas of skin with a blanched center. They can appear in different shapes and sizes, ranging from a few millimeters to several centimeters in diameter. These rashes can also occur in any region of the body.

8. How Can I Permanently Cure Urticaria?

The following are the methods that can aid in permanent cure of an urticaria reaction:
- Apply a cold compress several times a day. But avoid this method if cold triggers your hives.
- Use topical creams that you can buy in the medical shop without a prescription.
- If symptoms persist, consult a doctor.

9. Can Stress Cause Urticaria?

Chronic cases of urticaria can also be caused as a result of an immune response. An immune response can be triggered by various factors such as heat, extreme physical activity, or alcohol usage. Stress can also be a potential cause of urticaria and can aggravate it.

10. What Are the Best Antihistamine Medicines That Can Be Used for Urticaria?

The following are the antihistamine medicines that can be used for patients affected with an urticaria reaction:
- Loratadine.
- Fexofenadine.
- Cetirizine.
- Desloratadine.

11. What Are the Factors That Aggravate Urticaria?

The following are the list of physical factors that can aggravate an urticaria reaction
- Cold.
- Heat.
- Excessive sweating.
- Exercise.
- Pressure.
- Sunlight.
- Water.
- Vibration.

12. Does Urticaria Go Away If Untreated?

Even though hives are associated with several autoimmune conditions such as thyroid diseases and inflammatory bowel disease, treating the autoimmune condition cannot cure hives. However, in most affected people with chronic urticaria, the rashes will gradually disappear with time.

13. How Can Urticaria Be Prevented?

Urticaria can be prevented by following some simple lifestyle changes. The primary preventive measure is by avoiding triggers such as food and medicines. You should always ensure adequate personal hygiene. It can aid in preventing infections that can cause hives.

14. What Are the Reasons Behind the Urticaria That Occur at Night?

Along with our body's circadian rhythms, different health conditions can lead to itchy skin reactions. It is known to become worse at night. This occurs in skin diseases like eczema, psoriasis, and urticaria.

15. What Foods Act as Triggers for Urticaria?

The following are everyday food items that can trigger urticaria. Avoiding those foods from the diet can prevent and cure urticaria:
- Tomatoes.
- Food additives such as vinegar.
- Food preservatives.
- Wine.

16. What Is Known as Cold Urticaria?

Cold urticaria is defined as a skin condition in response to cold that occurs within minutes after the event of cold exposure. The affected region of the skin develops reddish rashes. It is known as hives.

17. What Is the Best Treatment for Cholinergic Urticaria?

The following are the best treatment options to cure cholinergic urticaria:
- Antihistamines.
- Leukotriene inhibitors.
- Immunosuppressives.
However, cholinergic urticaria has a higher chance of recurrence.

18. How Can I Cure Cold Urticaria?

There is no cure for cold urticaria. However, preventive methods can help avoid the condition. The primary preventative measure is avoiding cold exposure. These patients can also get some relief by using appropriate medication.