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Habif Clinical Dermatology > Chapter 6: Urticaria and Angioedema > Flashcards

Chapter 6: Urticaria and Angioedema Flashcards

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1
Q

What percentage of the population will have at least one episode of Urticaria?

A

20%

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2
Q

What length of time defines chronic urticaria?

A

Six weeks

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3
Q

What is the likelihood of determining the cause of urticaria

A

high probability for acute urticaria

Only 5 to 20% of the cases of chronic urticaria

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4
Q

what is a hive or wheal

A

a circumscribed, erythematous or white, non-pitting, edematous, usually pruritic plaque that changes in size and shape by peripheral extension or aggression during the few hours or days that the individual lesion exist.

The eczematous, central area (wheal) can be pale in comparison to the erythematous surrounding area (flare)

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5
Q

what is a major difference between hives and angioedema

A

angioedema is deeper than hives

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6
Q

angioedema without urticaria may suggest what

A

may indicate a C1 esterase inhibitor deficiency

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7
Q

what is the most important mediator of urticaria

A

histamine

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8
Q

what happens when the H1 receptors are stimulated by histamine

A

an axon reflex, vasodilation, and pruritus

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9
Q

what happens when H2receptors are stimulated

A

vasodilation occurs

H2receptors are also present on the mast cell membrane surface and, when stimulated, further inhibit the production of histamine.

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10
Q

What is a common cause of acute urticaria?

A

Histamine release that is induced by allergen (drugs, foods or pollens) and mediated by IgE is a common cause of acute urticaria, and particular attention should be paid to these factors during the initial evaluation.

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11
Q

What plays a key role in infantile urticaria?

A

Food origin is important. in one series it accounted for 62% of patients, more than drug etiology of 22%.

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12
Q

what type of hypersensitivity is associated with most cases of acute urticaria?

A

Type I.

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13
Q

What causes the histamine release of the type I hypersensitivity reaction?

A

Circulating antigens such as foods, drugs or inhalants interact with cell membrane-bound IgE to release histamine.

Food allergies are the most common cause of anaphylaxis.

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14
Q

What is an Arthus reaction?

A

Type III hypersensitivity reaction

Occurs with deposition of insoluble immune complexes in vessel walls. These complexes Are composed of IgG or IgM with an antigen such as a drug.

Complement-mediated acute urticaria can be precipitated by administration of whole blood, plasma, immunoglobulins, and drugs or by insect stings.

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15
Q

What causes the urticaria in a type III hypersensitivity reaction.

A

Urticaria occurs when the trapped complexes activate complement to cleave anaphylotoxins C5a and C3a from C5 and C3. C5a and C3a are potent releasers of histamine from mast cells.

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16
Q

What are some non-immunologic mediators that cause the release of histamine

A

pharmacologic mediators, such as acetylcholine, opiates, polymyxin B, and strawberries, react directly with the cell membrane bound mediators to release histamine.

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17
Q

What is the pathogenesis of chronic urticaria?

A

Cutaneous mast cell release of histamine.

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18
Q

True or false:

over 30% of chronic urticaria patients have an autoimmune phenomena

A

true

Positive autologous serum skin test, antibodies to the alpha subunit of the basophil IgE receptor and to IgE, and thyroid autoimmunity.

Be sure to rule out physical urticaria.

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19
Q

what is the differential diagnosis of chronic urticaria

A
  1. Cutaneous lupus erythematosus
  2. Urticarial Vasculitis
  3. Urticaria pigmentosa
  4. Sweet’s syndrome
  5. Fixed drug eruption
  6. Bullous pemphigoid
  7. Muckle-Wells Syndrome (urticaria-deafness-amyloidosis syndrome)
  8. Chronic infantile neurologic cutaneous articular syndrome (neonatal onset multisystemic inflammatory disease)
  9. Schnitzler’s syndrome
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20
Q

should a biopsy taken of the urticarial plaque?

A

Yes. Patients with hives that are characteristic of urticarial vasculitis should have a biopsy taken of the urticarial plaque.

These hives burn rather than hitch and last longer than 24 hours.

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21
Q

what is the first-line treatment of urticaria

A

Non-sedating H1 antihistamines (Allegra 180 mg daily)

H2 receptor antagonist have few side effects and may be useful as an adjunct to therapy

Patients who have no response to any of these approaches may respond to immunotherapy with 200 to 300 mg of cyclosporine per day

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22
Q

what is the mechanism of action of antihistamines for the treatment of urticaria?

A

Antihistamines control urticaria by inhibiting vasodilation and vessel fluid loss.

Antihistamines do not block the release of histamine. If histamine has been released before anti-histamine is taken the receptor sites will be occupied in the antihistamine will have no effect

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23
Q

in addition to anti-histamines, what is an adjunct of therapy that can be used to treat urticaria in the anxious or depressed patient?

A

Doxepin

Initial dose is 10 to 25 mg. Gradually increased does up to75 mg for optimal control

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24
Q

what side effects are associated with antihistamines

A

antihistamines are structurally similar to atropine; therefore the produce atropinelike peripheral and central anticholinergic effects such as dry mouth, blurred vision, constipation, dizziness

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25
Q

what type of antihistamine receptors are in the skin

A

85% of histamine receptors in the skin or the H1 subtype

15% are H2 receptors

Studies suggest that the combination of H1 and H2 blockers do not improve treatment

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26
Q

What is the mechanism of action for doxepin

A

Doxepin is a tricyclic antidepressant

– potent blockers of histamine H1 in H2 receptors

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27
Q

What are second line treatment options for urticaria

A
  1. Oral corticosteroids
  2. Leukotriene modifier.
  3. Dapsone
  4. Calcineurin inhibitors
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28
Q

At what dosage should you use oral corticosteroids for treatment of urticaria

A
  1. Prednisone 40 Mg Per Morning or 20 Mg Twice per Day

2. Prescribe thirty 20 Mg Tablets. Patient Takes Five Day of 60 Mg, 40 Mg, and 20 Mg Each Morning

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29
Q

For the treatment of urticaria, how long before leukotriene modifier becomes effective

A

several weeks

Montelukast was demonstrated to be effective for patients with NSAID-exacerbated chronic urticaria

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30
Q

what should be considered before starting Dapsone Therapy

A

G6PD

- Obtain a G6PD level to avoid more severe hemolytic anemia in G6PD deficient patients

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31
Q

What calcineurin Inhibitor Is Useful for the Treatment of Urticaria

A

Cyclosporine

Patients with Severe Unremitting Disease to Respond Poorly to Antihistamines May Respond to 4 Mg/KgDaily of Cyclosporine for Four Weeks

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32
Q

What Are Third Line Agents for the Treatment of Urticaria

A
  1. IV IG
  2. Methotrexate
  3. Topical Measures (Aveeno, Sarna, Itch X)
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33
Q

what is Darier’s sign

A

when mechanical event elicits whealing in 1 to 3 minutes after con

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34
Q

what is pressure urticaria

A

a deep, burning, or painful swelling occurring 2 to 6 hours after a pressure stimulus and lasting 8 to 72 hours

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35
Q

what is the treatment for pressure urticaria

A

systemic steroids given in short duration tapers are the most effective treatment for severe, disabling delayed pressure urticaria

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36
Q

what is cholinergic urticaria

A

in its milder form, heat bumps. The most common of the physical urticaria

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37
Q

What are the clinical features of cholinergic urticaria?

A

Round, papular wheals 2 to 4 mm in diameter that are surrounded by slight to extensive red flare.

Typically the hives occur during or shortly after exercise.

Cholinergic urticariamay become confluent and resemble typical hives

38
Q

How is cholinergic urticaria diagnosed

A

the most reliable and efficient testing method is to ask the patient to run in place or use the exercise bicycle for 10 to 15 minutes, and then to observe the patient for one hour to check with typical micro papular hives.

39
Q

What is the treatment for cholinergic urticaria

A

Zyrtec and twice its recommended dose of 20 mg is very effective.

40
Q

What is exercise-induced anaphylaxis

A

Exercise acts as a physical stimulus that, through an unknown mechanism, provokes mast cell granulation and elevated serum histamine levels.

41
Q

What is thought to provoke (EIA) exercise-induced anaphylaxis or exercise-accentuated anaphylaxis

A

may occur only after ingestion of certain foods such as celery, shellfish, wheat, fruit, milk and fish

Attacks occur when the patient exercises within 30 minutes after ingestion of the food; eating the food without exercising (and vice versa) causes no symptoms.

42
Q

What is the treatment for exercise-induced anaphylaxis?

A

H1 antihistamines were recommended as pretreatment and acute therapy.

43
Q

What is cold urticaria?

A

A group of disorders characterized by urticaria, angioedema, or anaphylaxis that develop after cold exposure.

44
Q

What finding in a patient’s history is common with primary cold urticaria

A

recent history of a virus infection (Mycoplasma pneumoniae)

45
Q

what age group is typically affected by primary acquired cold urticaria?

A

Children and young adults

46
Q

what is the most common cause of severe reactions with primary acquiredcold urticaria?

A

swimming in cold water is the most common cause of severe reactions and can result in massive transudation of fluid into the skin, leading to hypotension, fainting, shock, and possibly death.

47
Q

What is secondary acquired cold urticaria

A

only 5% of patients with cold urticaria.

Additional Labs should be order: CBC, ESR, ANA, mononucleosis spot test, RPR, rheumatoid factor, total complement, cryoglobulins, cryofibrinogens, cold agglutinins, and cold hemolysins.

48
Q

what is solar urticaria

A

hives that occur in Sun-exposed area minutes after exposure to the sun and disappear in less than one hour

49
Q

what is Aquagenic pruritus

A

severe, prickling skin discomfort without skin lesions occurs within 1 to 15 minutes after contact with water at a temperature and last for 10 to 120 minutes

50
Q

what role does histamine play with Aquagenic pruritus

A

histamine does not play a role in the pathogenesis

51
Q

what is angioedema?

A

hive-like swelling caused by increased vascular permeability in the subcutaneous tissue of the skin and mucosa and the submucosal layers of the respiratory and GI tracks.

52
Q

What are three types of hereditary angioedema?

A

Type I: deficiency of C1 INH protein
type II: dysfunctional C1 INH protein
type III: coagulation factor VII gene mutation

53
Q

What are two types of acquired angioedema

A

Type I: associated with lymphoproliferative diseases

type II: Autoimmune (anti-C1 INH antibody)

54
Q

What induces most cases of angioedema?

A

Most cases of angioedema or idiopathic

55
Q

What are the general types of angioedema?

A 
– Hereditary angioedema
 – acquired C1 inhibitor deficiency
 – inherited angioedema with normal C1 inhibitor levels
– ACE I – associated angioedema
– idiopathic angioedema
– allergic angioedema
– NSAID associated angioedema
– angioedema with the urticarial vasculitis
56
Q

What is the time of onset for ACE – I associated angioedema?

A

The onset usually occurs within hours to one week after starting therapy.

57
Q

Type I acquired angioedema is associated with what?

A

Type I is associated with lymphoproliferative diseases, including monoclonal gammopathy of unknown significance and high-grade lymphomas

58
Q

Type II acquired angioedema is caused by what process?

A

Thought to because to by an auto antibody to the C1 INH protein.

59
Q

Angioedema may be the first symptom of an internal disease, and proceed by how much time?

A

Angioedema can precede internal disease by up to seven years

60
Q

What is the treatment of acquired angioedema type I?

A

Treatment of underlying lymphoproliferative disease is often curative.

61
Q

What is the most common type of hereditary angioedema?

A

There are two types: type I being the most common at 85% of cases, type II with 15% of cases.

62
Q

What defines type I hereditary angioedema?

A

Characterized by an insufficient production of C1 inhibitor.

63
Q

What defines type II hereditary angioedema?

A

Have normal to elevated concentrations of C1 inhibitor, but the protein is functionally deficient.

Spontaneous occurrences are seen in up to 25% of patients.

Most cases begin in late childhood or early adolescence

64
Q

Hereditary angioedema presents by what age?

A

Usually experience attacks by the second decade of life

65
Q

Angioedema occurs at what three sites?

A
  1. Subcutaneous tissue
  2. Abdominal organs
  3. Upper airway
66
Q

What is the most common type of contact urticaria?

A

The non-immunologic type is the most common and most benign. This form does not require prior sensitization

Anaphylaxis may occur after application of bacitracin ointment.

67
Q

What is contact urticaria?

A

Characterized by a wheal and flair that occur within 30 to 60 minutes after cutaneous exposure to certain agents. Direct contact of the skin with these agents may cause a wheals and flare response restricted to the area of contact, generalized urticaria, urticaria and asthma, or urticaria combined with and anaphylactoid reaction.

68
Q

How is the diagnosis of contact urticaria confirmed?

A

An open patch test may be performed by applying a drop of the suspected substance to the ventral form and observing the site for the wheal 30 to 60 minutes later.

69
Q

What is pruritic urticarial papules and plaques of pregnancy

A

(PUPPP) also known as polymorphic eruption of pregnancy

Affects between 1 and 130 and 1 and 300 pregnancies.

Most frequently in primagravitas and begins late in the third trimester of pregnancy (mean onset, 35 weeks) or occasionally in the early postpartum.

The initial lesions may be confined to the striae.

70
Q

What is the mean duration of the PUPPP

A

Six weeks, but the rash is usually not severe for more than one week.

Clearing in most cases before or within one week after delivery.

Recurrence with future pregnancies is unusual.

71
Q

What is thought to to play a role in the development of PUPPP

A

It was postulated that abdominal distention or reaction to it may play a role in the development of PUPPP

72
Q

What is urticarial vasculitis?

A

A subset of vasculitis characterized clinically by urticarial skin lesions and histologically by necrotizing vasculitis.

Immune complexes are thought to lodge in small blood vessels with activation of complement, mast cell degranulation, infiltration by acute inflammatory cells, fibrin deposition, and blood vessel damage.

73
Q

One of the two subgroups of urticarial vasculitis?

A
  1. Hypocomplementemia

2. Normal complement levels

74
Q

What is the most common cause of normal complement UV?

A

Idiopathic

75
Q

What is the most common cause of hypocomplementemia UV

A

May proceed a syndrome that includes obstructive pulmonary disease and uveitus, systemic lupus erythematosus, Sjogren’s syndrome or cryoglubulinemia.

76
Q

What is serum sickness?

A

It is a disease produced by exposure to drugs, monoclonal antibody therapy, blood products, or animal derived vaccines.

Circulating antibodies react with the newly introduced antigen to form precipitating antigen-antibody complexes.

77
Q

When do symptoms appear for serum sickness?

A

Symptoms appear 8 to 13 days after exposure to the drug or antisera and last for 4 or more days.

78
Q

What are the symptoms for serum sickness?

A 
Fever
malaise
skin eruptions
arthralgia
nausea and vomiting 
occult blood in stool 
lymphadenopathy

White blood cell count may be as high as 25,000

79
Q

What are the most common cause of serum sickness?

A

Drugs are the most common cause of serum sickness.

Penicillin
sulfa drugs
thiouracil
etc.

80
Q

What is mastocytosis

A

A group of rare diseases characterized by abnormal growth of mast cells in skin, bone marrow, liver, spleen, and lymph nodes.

Histamine is release by scratching the lesions or ingesting certain agents.

81
Q

What happens with mast cell degranulation occurs?

A

Cause episodic flushing, dyspepsia, diarrhea, abdominal pain, musculoskeletal pain, or hypotension

82
Q

What is the most common form of mastocytosis?

A

Cutaneous mastocytosis

83
Q

What is the most common cause of pediatric mastocytosis?

A

Sporadic and appeared during the first two years of life, especially on the trunk

Urticaria pigmentosa is the most frequent variant

84
Q

For the classifications of cutaneous mastocytosis according to the World Health Organization?

A
  1. Urticaria pigmentosa (UP)
  2. Diffuse cutaneous mastocytosis (DCM)
  3. Mastocytoma of the skin
85
Q

What should be considered in patients that develop cutaneous mastocytosis after the age of two?

A

Often accompany by systemic disease

86
Q

What is a solitary mastocytoma?

A

A larger solitary collection of mast cells

Their reddish-brown nodules are plaques that can be several centimeters in diameter. Stroking induces whealing (“Darier’s sign”)

Rare in adults, most common at birth or in first week of life.

Most occur on the extremities but not in the palms are soles

87
Q

What is urticaria pigmentosa

A

Second most frequent manifestation of mastocytosis in children

Maybe present at birth, may appear in infancy and childhood, is presence in 80% of affected individuals within six months.

88
Q

Discuss adult onset urticaria pigmentosa

A

If UP develops after age 10 is more likely associated with systemic disease. Mean age of onset is 26.5 years

Lesions are well demarcated, red-brown, slightly elevated plaques averaging 0.5 to 1.5 cm in diameter

The palms and soles are spared

89
Q

What is Telangiectasia macularis eruptiva perstans (TMEP)

A

TMEP is the rarest cutaneous form of mastocytosis.

Limited to adults and consist of telangectasias

90
Q

What is the most aggressive form of mastocytosis?

A

Mast cell leukemia

Occurs in fewer than 2% of patients

91
Q

What symptoms should make make you suspect mastocytosis

A

Mastocytosis should be suspected in patients with recurrent anaphylaxis who present with syncopal or near syncopal episodes without associate hives or angioedema

92
Q

What is the treatment for urticaria pigmentosa?

A

Patients may benefit from a combination of H1 and H2 histamine antagonists.

Application of 0.05% betamethasone under plastic film occlusion for eight hours daily for six weeks leads to control pruritus and Darier’s sign

Habif Clinical Dermatology (8 decks)

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