Urticaria and Angioedema - PowerPoint Presentation

Slide1

Urticaria and Angioedema

Jim Harris, MD

Allergy and Immunology

South Bend Clinic

Slide2

Slide3

Definition

Urticaria

(hives, welts, “whelps”)

Area of redness and swelling of various sizes,

with flare, raised , +/- central pallor

Itching (

pruritis

)

Time course <24

hrs

, skin returns to normal

Can occur anywhere on body

Angioedema

episodic

submucosal

or subcutaneous swelling

Skin normal color

Affects extremities- hands, feet, face, genitals

Lasts hours to several days

Painful, numb, or tingling, rather than itching

Acute

urticaria

- < six weeks duration

Chronic spontaneous

urticaria

-AKA chronic idiopathic

urticaria

Greater than 6 weeks duration

50% hives only

40% hives and angioedema

10% mostly angioedema

Slide4

j

Slide5

Causes

Idiopathic- 90% of chronic cases

Infections- most acute cases

IgE

mediated allergic reactions

Direct mast cell activation

Nonsteroidal

anti-inflammatories (NSAID’s)

Physical stimuli

Systemic

Diseases

Slide6

Causes

Infections

Viral, parasitic, bacterial

;

antibiotics

Up to 80% in pediatrics

Study: 88

peds

seen in ER w/ infection, on B-lactam antibiotics (

penicillins

/

cephalosporins

) and rash, 47/88 hives; on later challenge with same antibiotic, only 4/88 reacted

Conclusion: allergy to antibiotics

overdiagnosed

in children

Slide7

Infection

Sinusitis; acute and chronic

Most common identifiable cause of chronic hives in children

Can be subtle

Xrays

can be helpful;

esp

CT

Hives may persist even after treatment

Often need

abx

for 2-4 weeks, even surgery, to clear

Slide8

IgE mediated reactions

Medications- antibiotics, etc.

Stinging insects

Foods and food additives

Latex

Contact with allergens

Transfusions

Slide9

IgE mediated

Medications

V

irtually all, but especially antibiotics

Penicillins

and

cephalosporins

most common; may be labeled for life!

98% of PEN reactions resolve over 10 years

Skin testing confirms, even w/

hx

anaphylaxis, that allergy resolved

May further confirm with oral challenge; single dose

vs

10d course

Cost effective to R/O penicillin allergy, especially pre

surg

and IV

abx

Slide10

IgE- Foods

Usually within 30” of ingestion

Can cause chronic

sxs

Children: milk, egg, peanut, tree nuts, seeds; many resolve

Adults: shellfish, peanut, tree nuts; milk, egg

Food additives:

Yellow dye #5 (

tartrazine

)

Red dye #4 and #40- ADHD in kids

Slide11

Direct Mast Cell Activation

Cause histamine release

Narcotics- codeine, morphine

Muscle relaxants- perioperative

Vancomycin

- Red man syndrome

Certain foods- tomatoes, strawberries

Radiocontrast

media- can block with meds

Slide12

Physical Stimuli

Cold or heat induced

Vibration

Pressure

Exercise- 2 types:

Cholinergic

urticaria

Exercise induced anaphylaxis

Solar (

vs

polymorphous light eruption)

Aquagenic

- contact with water!

Stress?

Slide13

Dermatographism

AKA

Dermographism

Induced by stroking the skin

Often have chronic itch even if no hives

Differential:

Dry skin

Neurodermatitis

(anxiety)

Slide14

Systemic Causes

Infections

Sinusitis, prostatitis

Hepatitis

Autoimmune- lupus, RA

Renal disease

Cancer- lymphoma, myeloma

Thyroid disease

Hormonal- often cyclical

Mast Cell Disorders

Slide15

Mast Cell Disorders

Mastocytosis

-

Abnormal number of mast cells

Mast Cell Activation Syndrome- recent phenomena- 2007

Normal cells,

abnl

histamine release

Hives, usually chronic

Chronic rhinitis

Autonomic dysfunction

Irritable bowel, cystitis

Headaches, sleep dysfunction

Fibromyalgia

Ehlers-

Danlos

/

hyperflexible

Anaphylaxis

Slide16

Evaluation

History- events at or before onset

May be complex and detailed

Physical exam – be sure they have hives! Sinuses, HSM, nodes

Tests- limited, based on

hx

Systemic: CBC, ESR, CRP, CMP, TSH; ANA, RA

Tryptase

, +/- 24

hr

urine studies

Xray

- chest (lymphoma), sinus

Foods: for

IgE

reactions only

Skin tests; most sensitive

Blood tests; more expensive, less sensitive

Slide17

Slide18

Skin Biopsy ?

When?

Lesions last >24

hrs

Painful not pruritic

Respond only to steroids

What?

Often non-specific

Eos, neutrophils, lymphocytes

Immuno

tests for

vasculitis

; deposition of complement and antibodies

Best done by dermatology

Slide19

Treatment

Antihistamines

H1 antagonists

Second generation preferred- Allegra,

Zyrtec

(to 4/d) at least BID

First generation- more sedating, but may be more effective; hydroxyzine up to 100 bid

Benedryl

- most sedating, short half life

H2; ranitidine out, famotidine first choice, 20 bid; less effective

Leukotriene antagonists

Montelukast

(

Singulair

); short half life though 1x/d

Zafirlukast

(

Accolate

); dosing bid

Slide20

Treatment

Prednisone/ systemic steroids

Do not block mast cell degranulation, but…

Do reduce inflammatory mediators

Many ways to dose

Cyclosporin

/

Dapsone

-

H pylori? Thyroid antibodies?

Diet- no change, except MCAS

Biologics

Xolair

(

omalizumab

)

Others pending

Slide21

Xolair (omalizumab)

R

efractory hives (also asthma)

Monoclonal antibody

Binds to free

IgE

, not

IgE

bound to mast cells

Injections 150 or 300 mg every 2-4 weeks; well tolerated

0.1% risk of anaphylaxis;

Epipen

.

In 12 week study…

44% complete resolution of hives

66% reduction in itching

Cancer Risk? Minimal

Slide22

Angioedema

Less Common

Rule out hereditary angioedema

C1 esterase deficiency

If tests (+), many new drugs

If tests (-), treatment same as hives; preventive antihistamines, but steroids first line therapy

Workup and evaluation same

Slide23

Questions?

Thank you for your attentionThanks to Beacon and JenaiHappy Holidays!!!