Urticaria (Hives)

Question 1

Urticaria is the medical name for hives, which is a skin reaction that causes itchy welts, also called wheals. What are wheals (or welts)?

1 - dry itchy cysts
2 - oedematous papules due to dermal swelling
3 - allergic reaction causing a systemic eczema reaction
4 - can be any of the above

Answer 1

2 - oedematous papules due to dermal swelling

• papules are raised skin <0.5cm

Question 2

Urticaria is the medical name for hives, which is a skin reaction that causes itchy welts, also called wheals. Which of the following is NOT a common symptom patients with urticaria present with?

1 - transient itchy skin (very itchy)
2 - mucosal swelling
3 - present in all layers of the skin superficial dermis

Answer 2

3 - present in all layers of the skin
- typically confined to superficial dermis

• Wheals can be single, multiple, small or large

Question 3

Urticaria is the medical name for hives, which is a skin reaction that causes itchy welts, also called wheals. Which of the following is NOT a typical cause of urticaria?

1 - allergy
2 - burns
3 - autoimmunity
4 - drugs
5 - diet
6 - infections

Answer 3

2 - burns

Question 4

Which of the following has been identified as the most common cause of Urticaria?

1 - allergy
2 - autoimmunity
3 - drugs
4 - diet
5 - infections

Answer 4

1 - allergy

Question 5

Angioedema relates to swelling of the skin. Is this confined to the superficial or deep layers of the skin?

Answer 5

• affects deep layers of the skin

Question 6

Angioedema relates to swelling of the deep layers of the skin. Does this cause pain?

Answer 6

• yes
• often associated with pain

Question 7

What had been identified as a key component causing recurrent angioedema?

1 - cytotoxic T cell inhibitor deficiency
2 - B cell inhibitor deficiency
3 - mast cell inhibitor deficiency
4 - C1 esterase inhibitor deficiency

Answer 7

4 - C1 esterase inhibitor deficiency
- only known inhibitor of the complement pathway

Question 8

All of the following can be used to diagnose patients with angioedema and urticaria, except which one?

1 - history and clinical findings
2 - blood tests
3 - urine analysis
4 - physical and dietary challenges
5 - skin tests and biopsy

Answer 8

3 - urine analysis
- if a patient presents with just angioedema, need to check C1 esterase inhibitor levels

Question 9

Patients with urticaria typically present to primary care, emergency rooms, dermatologists or allergists. However, typically how long to the wheals/hives lasts for?

1 - <1h
2 - <6h
3 - <12h
4 - <24h

Answer 9

4 - <24h
- episodes can be prolonged though

Question 10

Patients with urticaria typically present to primary care, emergency rooms, dermatologists or allergists and typically only last up to 24h. Are wheals/hives always accompanied by angiodema?

Answer 10

• no
• urticaria can be alone
• urticaria can include angioedema
• urticaria can include angioedema and anaphylaxis

Question 11

What is the term given to urticaria when the wheals/hives last >24h?

1 - urticarial vasculitis
2 - angioedemitis
3 - urticarialitis
4 - systemic urticarial

Answer 11

1 - urticarial vasculitis

Question 12

Although the exact cause of urticaria remains unknown, the following have been identified in the potential pathophysiolohy:

• Mast cell stimulation
• Mast cell independent urticaria
• Prostaglandins
• Cyropyrins (node like receptors, involved in inflammatory pathways)

Answer 12

All of the following have been identified in the aetiology urticaria:

• Immunologic - autoimmune
• IgE dependent (type I)
• Immuno complex (type III)
• Kinin and complement dependant
• Non immunologic –direct mast cell activation(opiates) , vasoactive stimuli (wasp), aspirin, dietary pseudoallergens, ACEI
• Idiopathic

Question 13

Which of the following is NOT a real classification of urticaria?

1 - hand and foot urticaria
2 - spontaneous urticaria
3 - physical (inducible)
4 - urticarial vasculitis (>24h)
5 - contact urticaria
6 - angioedema without urticaria
7 - distinctive urticarial syndromes

Answer 13

1 - hand and foot urticaria

Question 14

Which of the following is the definition of chronic urticaria?

1 - lasting >6 weeks
2 - lasting >6 weeks at least twice a week
3 - lasting >12 weeks
4 - lasting >12 weeks at least once a week

Answer 14

2 - lasting >6 weeks at least twice a week

• <6 weeks it is called episodic /recurrent urticaria

Question 15

Ordinary/spontaneous urticaria can be acute and is commonly seen in which age group with atopic dermatitis (eczema)?

1 - babies
2 - young children
3 - teenagers
4 - adults

Answer 15

2 - young children

Question 16

Ordinary/spontaneous urticaria can be chronic and typically peaks at what age?

1 - 2nd decade
2 - 3rd decade
3 - 4th decade
4 - 5th decade

Answer 16

3 - 4th decade

Question 17

Urticaria can occur any time, but is it more common during the day or evening?

Answer 17

• evening

Question 18

Urticaria can be associated with all of the following, EXCEPT which one?

1 - pre-menstrual exacerbations
2 - fatigue
3 - osteoporosis
4 - chills
5 - arthralgia

Answer 18

3 - osteoporosis

Question 19

Which of the following conditions are associated with urticaria?

1 - Thyroid disease
2 - Vitiligo
3 - Insulin dependent diabetes
4 - Rheumatoid arthritis
5 - Pernicious anaemia
6 - Helicobacter pylori
7 - Strongyloidiasis
8 - all of the above

Answer 19

8 - all of the above
- strong autoimmune component

Question 20

Physical/inducible urticaria can be caused by exogenous stimuli. This can include which of the following?

1 - mechanical (dermographism, delayed pressure urticaria, vibratory)
2 - Temperature – heat, cold
3 - Sweat, stress- cholinergic, adrenergic, exercise induced
4 - Solar urticaria (heat)
5 - Aquagenic urticaria (water)
6 - all of the above

Answer 20

6 - all of the above

Dermographism can be:
- Simple or symptomatic
- Whealing occurs in response to gentle skin stroking
- Resolves in an hour
- No association with atopy
- Delayed dermographism

Question 21

Delayed pressure urticaria is another form of urticaria. Which of the following is NOT correct about this form of urticaria?

1 - deep erythematous swellings at sites of sustained pressure
2 - 30 seconds to 12 minutes
3 - pruritic/painful or both
4 - tight clothing , soles – after walking
5 - flu like symptoms, arthralgia
6 - vibratory angioedema

Answer 21

2 - 30 seconds to 12 minutes
- typically occurs between 30 minutes to 12 hours

Question 22

Urticaria due to temperature changes is another form of urticaria. Does heat urticaria typically occur quickly or slowly?

Answer 22

• quickly
• within minutes, can last hours

Question 23

Cholinergic urticaria is a form of urticaria caused by the sweat and are typically associated with stress. Which of the following occur?

1 - transient, papular 2-3 mm wheals with surrounding flare
2 - 15 minutes of sweat inducing stimuli
3 - common in young adults
4 - exercise induced anaphylaxis
5 - ood and exercise induced anaphylaxis - gliadin
6 - all of the above

Answer 23

6 - all of the above

• cholinergic urticaria is typically much smaller than standard urticaria

Question 24

Urticarial vasculitis is a form of urticaria. Which of the following are true about urticarial vasculitis?

1 - lasts for more than 24 hours
2 - can show bruise like skin changes
3 - burning than itching
4 - arthralgia, renal, ocular changes
5 - aistology – vasculitis
6 - all of the above

Answer 24

6 - all of the above

Question 25

All of the following can be used to diagnose acute urticaria, EXCEPT which one? 1 - IgE test 2 - IgG test 3 - RAST screen 4 - skin prick test

Answer 25

2 - IgG test Rast = Radioallergosorbent test, a laboratory test performed on blood. It tests for the amount of specific IgE antibodies in the blood which are present if there is a "true" allergic reaction.

Question 26

All of the following can be used to diagnose chronic urticaria, EXCEPT which one? 1 - skin prick test 2 - ESR 3 - CRP 4 - thyroid autoantibodies

Answer 26

1 - skin prick test - often autoimmune so can use this to diagnose patients

Question 27

How is physical urticaria diagnosed? 1 - skin prick test 2 - ESR 3 - CRP 4 - challenged with potential agent they came into contact with

Answer 27

4 - challenged with potential agent they came into contact with

Question 28

How is Urticarial vasculitis diagnosed? 1 - skin prick test 2 - ESR 3 - CRP 4 - skin biopsy

Answer 28

4 - skin biopsy

Question 29

How is angioedema without wheals diagnosed? 1 - low C4 level and/or C1 inhibitor levels 2 - ESR 3 - CRP 4 - skin biopsy

Answer 29

1 - low C4 level and/or C1 inhibitor levels

Question 30

What is typically the 1st line treatment for urticaria? 1 - prednisolone 2 - cyclosporine 3 - methotrexate 4 - antihistamines

Answer 30

4 - antihistamines - fexofenadine is 1st line - Classic antihistamines –sedation - Second generation antihistamines, preferred choice as no sedation - H1 and H2 antihistamines

Question 31

Which of the following is typically NOT a 2nd line treatment for urticaria? 1 - prednisolone 2 - Epinephrine (if anaphylaxis) 3 - Montelukast 4 - Antihistamines

Answer 31

4 - Antihistamines - prednisolone only in short courses, but is 1st out of the 3

Question 32

Which of the following is NOT a non-drug therapy that can be used to treat urticaria? 1 - Exclusion of food additives, salicylates 2 - Tolerance by repeated exposure 3 - Ultraviolet light 4 - Exercise

Answer 32

4 - Exercise

Question 33

Which of the following is NOT a 3rd line therapy for urticaria? 1 - Cyclosporine 2 - Flumazenil 3 - Methotrexate 4 - Mycophenolate mofetil 5 - Omalizumab – anti IGE monoclonal antibody

Answer 33

2 - Flumazenil - benzodiazepine antagonist

Question 34

If a patient is diagnosed with C1 esterase inhibitor deficiency, which of the following can be used to treat them? 1 - C1 concentrate for emergency use 2 - Fresh frozen plasma 3 - given as prophylaxis 1 hr before surgery 4 - oral tranexamic acid 5 - avoid oestrogen –OCP/HRT 6 - all of the above

Answer 34

5 - all of the above

Question 35

If a patient has been diagnosed with angioedema, which of the following should be used in their management? 1 - ABCDE 2 - Stop any trigger 3 - Antihistamines 4 - Steroids 5 - all of the above

Answer 35

5 - all of the above - can lead to anaphylaxis, asphyxia, cardiac arrest and death

Question 36

Once treated, typically how long before angioedema resolves? 1 - 1-3h 2 - 1-3 days 3 - 1-3 weeks 4 - 1-3 months

Answer 36

2 - 1-3 days