Otolaryngology Book

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HivesAka: Urticaria

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  1. See Also
    1. Allergic Reaction
    2. Angioedema
  2. Epidemiology
    1. Common (U.S. Prevalence up to 25%)
  3. Pathophysiology
    1. Response to histamine release from cutaneous mast cells
    2. Often seen with Angioedema
  4. Causes
    1. Allergic Urticaria
      1. Type I Hypersensitivity (IgE mediated immediate)
        1. See Allergic Reaction
        2. Medication reaction (e.g. Penicillins)
        3. Airborne allergans (e.g. pollens, mold spores)
        4. Hymenoptera Stings
        5. Parasitic Infection
        6. Illness
          1. Acute Infection
          2. Generalized inflammation
        7. Food reaction (e.g. Eggs, Nuts, gluten, shellfish)
          1. Transient in children (rare in adults)
          2. Must occur within minutes of exposure
      2. Type II Hypersensitivity (Cell mediated cytotoxicity)
        1. Transfusion Reaction
      3. Type III Hypersensitivity (Antigen-Antibody complex)
        1. Serum Sickness
    2. Autoimmune condition
      1. Hashimoto's Thyroiditis
      2. Systemic Lupus Erythematosus
      3. Chronic active hepatitis
    3. Viral Infection
      1. Herpes Simplex Virus (HSV)
      2. Cytomegalovirus (CMV)
      3. Epstein-Barr Virus (EBV)
    4. Direct mast cell degranulation
      1. Narcotics
      2. Vancomycin
      3. Aspirin
      4. Anaphylactoid Reaction to Radiocontrast
      5. Dextran
      6. Muscle relaxants
      7. NSAIDs
    5. Ingestion of foods concentrated in histamine
      1. Strawberries
      2. Tomatoes
      3. Shrimp or lobster
      4. Cheese
      5. Spinach
      6. Eggplant
    6. Emotional Stress
    7. Physical Urticaria
      1. Cold Urticaria
        1. Affects hands, ear, nose and lateral thighs
      2. Cholinergic Urticaria
        1. Fever
        2. Hot baths
        3. Exercise-Induced Urticaria
      3. Solar Urticaria (Sun induced)
      4. Pressure
        1. Tight clothing
        2. Soles of foot and other weight bearing points
        3. Dermatographism
  5. Types
    1. Acute Urticaria (present hours to weeks)
      1. Idiopathic in 75% of cases
    2. Chronic Urticaria (persistent beyond 6 weeks)
      1. Idiopathic in 95% of cases
      2. May be related to autoantibody to IgE
  6. Symptoms
    1. Pruritus
  7. Signs
    1. Characteristics
      1. Hives or wheals up to 1-2 centimeters in size
      2. Redness and edema of Dermis
      3. Spread with scratching and coalesce into large patch
    2. Course of Lesions
      1. Lesions last 90 minutes to 24 hours
    3. Associated findings
      1. See Allergic Reaction
      2. Angioedema
  8. Evaluation
    1. Recommended diagnostics
      1. Careful History
        1. Negative history makes finding cause very unlikely
        2. Travel and work history
        3. Ingestion of foods, medications, herbals, vitamins
        4. Recent infection
        5. Known allergies
        6. Family History of allergy or Thyroid disease
      2. Lab Tests
        1. Only if suggested by specific symptoms or signs
        2. Consider brief panel if suggested by history
          1. Complete Blood Count with differential
          2. Urinalysis
          3. Erythrocyte Sedimentation Rate (ESR)
          4. Liver Function Tests
          5. Thyroid Stimulating Hormone (TSH)
      3. Skin biopsy if lesion present >24 hours
        1. Consider urticarial Vasculitis
        2. Painful or burning leg lesions
        3. Biopsy show Neutrophilic infiltrate
    2. Diagnostic tests that are not recommended
      1. Radiologic studies
        1. Sinus XRay and Dental XRay have low yield
      2. Allergy Testing
        1. Not helpful in chronic urticaria
  9. Differential Diagnosis
    1. See also Wheal
    2. Urticarial Vasculitis (Leukocytoclastic Vasculitis)
      1. Painful leg lesions last 3-5 days
      2. Consider biopsy (shows Neutrophilic infiltrate)
  10. Management: General
    1. Observe for severe Allergic Reaction
      1. See Anaphylaxis
    2. Discontinue offending drugs, food, or behavior
    3. Offer Reassurance
      1. Discuss idiopathic nature of chronic urticaria
      2. Unlikely to identify a specific cause
    4. Explain that diagnostics and labs are not indicated
  11. Management
    1. Step 1: Non-Sedating Antihistamines
      1. Expensive: $2 per capsule
      2. Examples: Claritin, Allegra, Zyrtec
      3. Less effective antipruritic as Sedating Antihistamine
        1. Zyrtec, as analog of Atarax, may be more effective
      4. Consider for daytime urticaria symptom control
    2. Step 2: Sedating Antihistamines
      1. Consider for nighttime and refractory to step 1
      2. Hydroxyzine (Atarax) is the most potent of the class
      3. Beware Sedation in older patients and fall risk
      4. Indications and effects
        1. Helpful in Acute Hives in first few weeks
        2. Suppresses itching, and reduces lesions
        3. Does not completely eradicate lesions
    3. Step 3: Add H2 Receptor Antagonist
      1. H2 Blockers are rarely helpful
      2. Ranitidine 150 mg PO bid or
      3. Cimetidine 400 mg PO bid
    4. Step 4: Add combined H1 and H2 Receptor Antagonist
      1. Doxepin (Sinequan)
        1. Dose: 25-75 mg PO qhs
        2. Very potent Antihistamine (H1 and H2 Blocker)
          1. Doxepin is 700 times more potent than Benadryl
          2. Doxepin is 50 times more potent than Atarax
      2. Cyproheptadine (Periactin) 4 mg PO tid
    5. Step 5: Leukotriene modifier
      1. Montelukast (Singulair) 10 mg PO qd
      2. Zafirlukast (Accolate) 20 mg PO bid
    6. Step 6: Systemic Corticosteroids
      1. Prednisone 20-40 mg PO qd
      2. Indication
        1. Chronic urticaria not responding to Antihistamines
        2. Unlikely to help in early or acute urticaria
      3. Efficacy
        1. Process will flare when steroids are weaned
    7. Step 7: Consult allergy or dermatology
  12. Resources
    1. Wanderer (2003) Hives: Road to Diagnosis and Treatment
      1. Paid Link to Amazon.com (ISBN 0972794808)
  13. References
    1. Frank in Goldman (2000) Cecil Medicine, p. 1440-5
    2. Kaplan in Middleton (1998) Allergy, p. 1104-18
    3. Habif (1996) Clinical Dermatology, p. 122-47
    4. Greaves (2000) J Allergy Clin Immunol 105:664
    5. Muller (2004) Am Fam Physician 69(5):1123

Urticaria (C0042109)

Definition (MSH)A vascular reaction of the skin characterized by erythema and wheal formation due to localized increase of vascular permeability. The causative mechanism may be allergy, infection, or stress.
Definition (CSP)usually transient vascular reaction involving the upper dermis, representing local edema caused by dilation and increased permeability of the capilliaries and the development of wheals.
Definition (NCI)Urticaria.
Definition (NCI)An itchy skin eruption characterized by weals with pale interiors and well-defined red margins; usually the result of an allergic response to insect bites or food or drugs.
ConceptsDisease or Syndrome (T047)
ICD9708, 708.9, 708.9
MSHD014581
BasqueURTIKARIA
DanishUrticaria
DutchUrticaria
EnglishHive, Hives, RASH URTICARIAL, Unspecified urticaria, Urticaria, Urticarial rash, Urticarias
FinnishNOKKOSROKKO/URTICARIA
FrenchUrticaire
GermanUrtikaria
Hebrewurtikaria
Hungarianurticaria
ItalianOrticaria
NorwegianELVEBLEST/URTICARIA l50
PortugueseUrticaria
Spanisherupcion urticariana, papula urticariana, Urticaria
SwedishNASSELUTSLAG/URTICARIA
Parent ConceptsDermatitis (C0011603), skin disorder (C0037274), Exanthema (C0015230), Hypersensitivity (C0020517), Dermatoses, General and NEC (C0549580), Urticaria (C0042109), Other skin and subcutaneous tissue disease NOS (C0178301), Diagnosis/Diseases Component (C0497531), Skin (C1123023), Immediate hypersensitivity (C0020523), Skin Diseases, Vascular (C0162819), Edematous skin (C0521464), Edema (C0013604), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, CST, DXP, ICD9CM, ICPC, ICPCBAQ, ICPCDAN, ICPCDUT, ICPCFIN, ICPCFRE, ICPCGER, ICPCHEB, ICPCHUN, ICPCITA, ICPCNOR, ICPCPOR, ICPCSPA, ICPCSWE, LCH, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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