Transcript RHINITIS, SINUSITIS

Urticaria and
Angioedema 101
Scot Laurie, MD
Allergy and Asthma Center at
NorthPark
Assistant professor, University of
Texas Southwestern Medical
Center
Case Presentation



Jim S. is a 45 y/o who presented for
evaluation of his urticaria. He has been
suffering with hives for the past 4 months.
He is unable to tell what triggers his hives.
His hives are generalized and an individual
hive will last a few hours; he has had several
episodes of lip swelling as well.
He might have had a similar episode 10 years
ago and his doctor told him he was allergic to
penicillin
Case presentation


He has visited his primary care
physician who suggested he take
Claritin
He returned when his hives persisted
and the doctor told him that he was
allergic to something and suggested
an allergy evaluation.
Case presentation

Past medical history
– Hypothyroidism

Medications
– levothyroxine
– Ibuprofen prn

Review of systems
– Occasional headaches; otherwise
negative

Physical exam
Case presentation





How would his hives be classified?
What is causing his hives?
Are his medical conditions or
medications contributing to his hives?
What tests should be done to evaluate
his hives?
How are his hives best treated?
URTICARIA & ANGIOEDEMA

DESCRIPTION
– Urticaria
 Raised, erythematous, blanching
 Pruritic
 Lesions well-circumscribed; typically
coalesce
– Angioedema
 Subcutaneous swelling
 Predilection to areas of loose
connective tissue, such as the face or
mucus membranes involving the lips or
the tongue
Urticaria or
“Hives”
Urticaria and Angioedema

Clinical features: Urticaria
– Repeated occurrence of short-lived
cutaneous wheals accompanied by
erythema and pruritus
Wheals range in size from a few millimeters
to several centimeters
 Wheals may coalesce to form larger lesions
 Individual wheals typically last less than 24
hours
 Urticaria may occur anywhere on the skin

– Mucus membrane involvement is rare

Lesions should resolve without any residual
marking
Urticaria and Angioedema

Clinical features: Angioedema
– Approximately 50% of patients with
chronic urticaria have angioedema as well
– Episodes of short-lived deep dermal and
subcutaneous or submucosal edema
– Like urticaria, symptoms generally last
less than 24 hours

Larger swellings may take longer to resolve
– Pruritus does not consistently accompany
angioedema, and may not occur at all.
Mediators of hives and
swelling
Source
Mast cells (cutaneous)
Factor
Histamine
Prostaglandin D2
Leukotrienes C and D
Platelet Activating Factor
Complement system
Hageman factordependent pathway
Mononuclear cells
Anaphylatoxins C3a, C4a,
C5a: histamine
Bradykinin
Histamine-releasing
factors, chemokines
Urticaria and Angioedema

Classification
– Acute: < 6 weeks



Allergic
Infectious
Idiopathic
– Recurrent acute
– Chronic: > 6 weeks



Idiopathic
Autoimmune
Physical
URTICARIA CLASSIFICATION

Acute: < 6 weeks
– Affects as many as 10-20% of the
population at some point in their lives
– Etiology frequently identified
Food allergy
 Drug allergy
 Stings/venoms
 Infection

– Viral infection leading cause of urticaria in
children
Urticaria Classification

Recurrent acute (intermittent)
– Episodes of urticaria lasting days or
weeks with intervals of days, weeks, or
months in between episodes

Chronic: > 6 weeks
– Idiopathic
– Physical urticarias
URTICARIA ETIOLOGIES

Common
– Idiopathic
– Medications
– Stings
– Foods
– Infection
– Physical
urticarias

Rare Causes
– Neoplasms
– Collagen vascular
disease
– Endocrine
– Urticarial vasculitis
Urticaria etiologies


Urticaria is rarely, if ever the
presenting or sole symptom of an
underlying disease
A complete Review of Systems will
suggest or identify any systemic
disease in which the urticaria occurs
URTICARIA ETIOLOGIES

Medications
– Any drug has the potential to elicit an
allergic reaction
Antibiotics in general, and penicillins
specifically, are most often indicated
 Aspirin/NSAID’s



Considered second most common cause of
acute drug allergic reactions
Frequently exacerbate chronic urticaria and
angioedema
URTICARIA ETIOLOGIES

Foods

Important cause of acute urticaria
– Primary allergens are peanuts, tree nuts, shellfish,
fish, eggs, milk


Chronic urticaria typically unrelated to food
allergy
Infection

Common cause of acute urticaria
– Viral infection most common cause in children
– Episodes are self-limited

Rare cause of chronic urticaria
INSECT BITES & STINGS

Generalized urticaria/angioedema
– Indicates systemic reaction
– Requires allergist evaluation for possible
immunotherapy

Urticaria in children does not require
immunotherapy
– Hymenoptera
 bees, wasps, yellow jackets, hornets
 Fire ants
URTICARIA ETIOLOGIES

Aeroallergens
– Rarely, if ever, cause urticaria
Animals may cause contact urticaria
 Inhaled latex may result in systemic allergic
reaction
 ? seasonal pollens


Contact Urticaria
– Nonimmunologic
cinnamic acid, benzoic acid
 Diagnosed by open patch test

– Immunologic (Allergic)
Latex, fruits, vegetables
 Diagnosed by applying material to
eczematous or scratched skin

Urticaria etiologies

Endocrine/autoimmune
– Thyroid disease
Urticaria and angioedema has been
associated with hypo- and hyperthyroidism
 Possible association with the presence of
thyroid autoantibodies (antithyroid peroxidase
and antithyroglobulin)

– Thyroid autoimmunity has been demonstrated in
12-26 % of subjects with chronic urticaria
– Thyroid autoimmunity occurs in 3-6% of the
population
URTICARIA ETIOLOGIES

Chronic urticaria
– Most common etiology is idiopathic
– 30-60% of patients exhibit a wheal-and-flare
with autologous serum skin testing

Thought to be due to a complement-activating,
histamine-releasing autoantibody (IgG) against the αchain of the high-affinity IgE receptor (FcεRI)
– These autoantibodies are able to trigger mast cell or
basophil histamine release through direct crosslinking of
adjacent receptors
– Can cause histamine release in healthy subjects

Treatment implications: urticaria may be more difficult
to control
Plasma of patients with chronic urticaria shows
signs of thrombin generation, and its
intradermal injection causes wheal-and-flare
reactions more frequently than autologous
serum
J Allergy Clin Immunol 2006;117:1113-7.
Chronic urticaria: etiologies



51/96 (53%) patients had positive ASST
61/71 (86%) patients had positive APST
Prothrombin fragment F(1+2) (marker of
thrombin generation) was higher in patients
than in controls
– Levels directly related to severity of urticaria
Chronic urticaria: etiologies

Conclusions
– Suggests role of the activation of the
extrinsic coagulation pathway with
thrombin generation in chronic urticaria
Thrombin increases vascular permeability
(edema)
 May trigger mast cell degranulation

– Possible therapeutic use of anticoagulants
(heparin/warfarin)
Natural history:
Chronic Urticaria





Up to 50% patients resolve within 3-12
months
Another 20% of patients resolve in 12-36
months or 36-60 months
Up to 1.5% of patients persist for 20+ years
50% of patients with chronic urticaria will
have recurrences
Physical urticarias tend to last longer, as do
more severe forms of chronic urticaria
PHYSICAL URTICARIAS








Symptomatic dermographism
Cholinergic
Delayed pressure
Cold
Aquagenic
Solar
Vibratory
adrenergic
PHYSICAL URTICARIAS

Dermographism
– Very common- affects 2-5% of population

Small fraction of these patients will seek
treatment
– Stroking of the skin results in linear
wheals which may persist as long as 30
minutes

patients may complain of generalized
pruritus or “skin crawling”
PHYSICAL URTICARIAS

Cholinergic urticaria
– Likely the most common of the physical
urticarias- 30% of the physical urticarias
– Occurs primarily in teenagers and young
adults
– Pruritic, small macules and papules occur
in response to heat, exercise, or
emotional stress
May occur with wheezing
 May occur without visible skin lesions
(cholinergic pruritus)

Physical urticarias

Cold urticaria
– Characterized by the rapid onset of pruritus,
erythema, and swelling after exposure to a cold
stimulus



Holding cold objects: hand swelling
Eating cold items: lip swelling/ oropharyngeal edema
Swimming, with total body immersion, can result in
massive mediator release, resulting in hypotension
– Risk factor: oral symptoms with ingestion of cold items
URTICARIA EVALUATION

Acute urticaria and angioedema
– History to ascertain for possible
triggers: food, drug, sting, infection
– Exam to confirm diagnosis
– May refer to board-certified allergist
for select skin testing/challenge tests
to suspected agents
Urticaria evaluation

Chronic urticaria
– History and physical exam

Confirm diagnosis of urticaria/angioedema
– Laboratory studies

Usually none required
– No relationship has been found between the number of
identified diagnoses and the number of laboratory tests
performed


Consider thyroid evaluation (TSH, thyroid
autoantibodies) in patients who fail initial therapy
If urticarial vasculitis suspected:
– ANA, complement levels
– Referral for skin biopsy
Skin biopsy

Indications
– Individual urticarial lesion persists for >48
hours
– Urticaria are less than moderately pruritic
– Lack of significant response to
“maximum” doses of antihistamines
URTICARIA MANAGEMENT



Goals
– control symptoms & keep patient
comfortable
 search for and treat underlying etiologies
 exclude serious diseases
Avoidance
– causative factor if identified
– NSAID’s & ASA
– excessive heat
Supportive therapy
– Reassurance
– Patient education is most important
Urticaria management

Chronic idiopathic urticaria
– Because there is no one specific causative
agent that can be withdrawn, the hives
cannot be “cured”.
– Treatment is considered palliative, until
the condition resolves on its own

Goal is to maintain a patient’s quality of life,
despite condition
INITIAL URTICARIA
PHARMACOTHERAPY

Antihistamines: H1 receptor antagonists
– Second generation (“Non-sedating”)
 equal in efficacy to first generation without as
many side effects
– cetirizine, levocetirizine, desloratadine,
fexofenadine, loratadine
– First generation
 Generally administered on a daily basis for
preventative therapy
– hydroxyzine, diphenhydramine,
chlorpheniramine, etc.
– dose at qhs initially to reduce daytime
somnolence
– May be used on a prn basis
SECONDARY URTICARIA
PHARMACOTHERAPY



H2 antagonists
– 15% of histamine receptors in the skin are H2
– May use in combination with H1 antagonists
– Inhibits metabolism of hydroxyzine, resulting in higher
plasma concentration of hydroxyzine
Doxepin
– Very potent H1 antagonist
– H2 antagonist as well
– May be very sedating- generally use at night
Leukotriene antagonists
– Zafirlukast and montelukast superior to placebo in the
treatment of chronic urticaria
Urticaria management

Antihistamine “cocktail”
– Begin with 2nd generation antihistamine once a
day; if response unsatisfactory,
– Double the dose (either split-dose twice daily, or
full dose once daily); if response unsatisfactory,
ADD
– Doxepin 10-50 qhs (titrate over time to reduce
sedation)
Levocetirizine/cetirizine>fexofenadine>desloratadine/
loratadine
SECONDARY URTICARIA
PHARMACOTHERAPY

Oral corticosteroids
– Role of systemic steroids in the treatment
of chronic urticaria is limited
– Short-term use in special situations (e.g.
control of symptoms prior to an important
event.)
– Prolonged treatment complicated by
severe side effects along with worsening
of urticaria upon withdrawal
Alternative agents for
refractory chronic urticaria
Drug
Leukotriene modifiers
Dapsone
Sulfasalazine
Hydroxychloroquine
Colchicine
Calcineurin inhibitors
Mycophenolate
Omalizumab
Level of
evidence
Ib
IIb
III
Ib
III
Ib
IIb
III
SECONDARY URTICARIA
PHARMACOTHERAPY

Immunomodulatory agents
– Limited studies demonstrate efficacy of
cyclosporine in improving urticaria along
with decreasing dependence on
prednisone.
Suppressive effect on basophil and mast cell
activation
 Requires monitoring of a patient’s blood
pressure and renal function

Cyclosporine

Patients with chronic, severe urticaria with
positive autologous skin test
– 3-month course of treatment resulted in 80%
totally or almost clearing their symptoms
– Upon medication withdrawal at 3 months:



1/3 remained clear
1/3 relapsed mildly
1/3 relapsed to baseline
Br J Dermatol 2000;143:368.
Urticaria and angioedema

Pearls
– Urticaria and angioedema frequently is not an allergic
condition
– Urticaria does not respond to topical treatment
– Urticaria in the setting of antibiotics use might be due to
the infection, rather than the antibiotic
– Almost all urticaria is responsive to antihistamines; if your
initial dose does not work, use more
– When all else fails, refer to your favorite fellowship-trained
allergy and immunology specialist
– Treatment references: N Engl J Med 2002;346:175-9
or Allergy and Asthma Proc 2004;25:143-149.
I Need an Allergist!!