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URTICARIA
PresenterAimi Haniza Zainal
Glendy
Advisordr. Nasriyani Zainal
Supervisordr. Safruddin Amin, Sp.KK (K), MARS
INTRODUCTION
URTICARIA
vascular reaction in the skin local edema which rapidly arise & disappear slowly pale and red rises on the skin surface its surroundings can be surrounded by halo.
Acute
If the attack lasts < 6 weeks, or last for 4 weeks but arise every day. More common in young people, generally men more often than women. Most causes : adverse effects of food or due of viral illness.
Chronic
Duration of > 6 weeks Common in middle-aged women Most causes : idiopathic urticaria, or autoimmunity
Predisposing agent
Age
Race
Hygiene
Sex
Hereditary
Environment
EPIDEMIOLOGY
Found 40% of urticaria only, 49% urticaria
together with angioedema and 11% of
angioedema alone. The lifetime occurence of urticaria in the
general population ranges from 1% to 5%.
ETIOLOGY
Medications Food Insect Bites Inhalants
Penicillin drug
Insect wasp
Physical trauma cold,heat, pressure
and stressInfectionSystemic disease
Dermagraphism
Cold urticaria
PATHOGENESIS
(A) Non- immunologic factor
The chemical mediator release
Physical Factors(heat, cold, trauma,light)
Cholinergic effects
Mast cell Basofil
Mediator release(histamine, SRSA,
serotonin, quinine, PEG, PAF)
Vasodilatation↑ capiler
permeability
AlcoholEmotion
Fever
Urticaria
(B) Immunologic factor
Type 1 reaction (IgE)
Type IV reaction (contact)
complement activation: a) Type II reactionb) Type III reactionc) Genetic factor (C1
esterase inhibitor deficiency)
Mast cell Basofil
Mediator release(histamine, SRSA,
serotonin, quinine, PEG, PAF)
Vasodilatation↑ capiler
permeability
Urticaria
CLINICAL FEATURES
Urticaria looks like red skin raised above skin , on any part of the body
Itchy, painful, and hot or burning sensation
Can be in form of papular , lentikular, numular until plaques
• When it extends into the dermis and / subcutaneous and submucosal layer, it is called ‘angioedema’.
•Individual lesions of urticaria arise suddenly, rarely persistent longer than 24-48 hours, and may recur for indefinite period
PICTURES
CLASSIFICATION
Type of urticaria Example1) Ordinary urticaria - Acute & chronic urticaria
2) Physical urticaria - Adrenergic urticaria
- Cholinergic urticaria
- Aquagenic urticaria
- Cold urticaria
- Delayed pressure urticaria- Dermographism- Exercise-induced anaphylaxis- Localized heat urticaria- Solar urticaria- Vibratory angioedema
Type of urticaria Example3) Contact urticaria - Induced by biologic
or chemical skin contact
4) Urticarial vasculitis - Defined by vasculitis as shown by skin biopsy specimen
5) Angioedema without wheals
- Can be caused by idiopathic
Physical Examination
Dermagraphism : Stroke the armIce (ice cube test) or warm water if it is
suspected allergy to a certain temperatureSolar : perform photo paste test.Cholinergic : Intradermal mecholyl
injection can be used to diagnose the cholinergic urticaria
DIAGNOSIS
Allergen testing
1) Skin tests (prick test).
2) Radioallergosorbent tests (RAST) for
hipersensitivity type 1 reaction.
3) Oral challenge testing for food and food
additives.
4) To know the existence of vasoactive factors such as histamine-releasing autoantibodies, intradermal injection test using serum of patients themselves (autologous serum skin test-ASST) can be used.
1) CBC with differential, erythrocyte sedimentation rate (ESR) and urine routine.
Laboratory tests
2) Examination on complement, autoantibodies, elektrofloresis serum, kidney function, liver function and urinalysis
3) Examination of complement C1 inhibitor and C4
DIFFERENTIAL DIAGNOSE
Purpura anaphyla
toid
Erythema
Multiforme
Pityriasis rosea
Purpura anaphylatoid
Lesion : begins as erythematous macular or urticarial lesions, progressing to blanching papules, and later, to palpable purpura.
Pityriasis rosea
• The rash starts with a single large patch called a herald patch.• After several days, more skin rashes will appear on the chest, back, arms, and legs.
Erythema multiforme
• Lesion can be in form of macules, papules or urticaria.• First, spread commonly at lower extremities, palms and backs.
The most ideal treatment is to treat the cause or if possible avoid the cause of the suspect.
If not possible at least try to reduce the causes of these, at least do not use and do not contact with the cause
TREATMENT
1st line treatment
Non-or low-sedating H1 antihistamines
If little or no response
Increase above licensed doseAdd sedating H1 antihistamine at night
If little or no response
Add H2 antagonist
Class Examples Daily adult dose
Classic (sedating) Chlorpheniramine 4 mg tid (up to 12
mg at night)
Hydroxyzine 10–25 mg tid (up to
75 mg at night)
Diphenhydramine 10–25 mg at night
Doxepin 10–50 mg at night
Second-generation Acrivastine 8 mg tid
Cetirizine 10 mg once daily
Loratadine 10 mg once daily
Mizolastine 10 mg once daily
Class Examples Daily adult dose
Newer second-
generation
Desloratadine 5 mg once daily
Fexofenadine 180 mg once daily
Levocetirizine 5 mg once daily
H2 antagonists Cimetidine 400 mg bid
Ranitidine 150 mg bid
2nd line treatment
Systemic corticosteroids
Epinehrine
Others(determined by history and
investigations)
Combination therapies (e.g including doxepin)
2nd line treatment
Generic name Drug class Dose
Prednisone Corticosteroid 0.5 mg/kg qd
Epinephrine Sympathomimetic 300–500 mg
Montelukast Leukotriene receptor
antagonist
10 mg qd
Thyroxine Thyroid hormone 50–150 mg qd
Nifedipine Calcium antagonist 10–40 mg
modified-release qd
Colchicine Neutrophil inhibitor 0.6–1.8 mg qd
Sulfasalazine Aminosalicylates 2–4 g qd
3rd line treatment
Immunotherapy• No response to 1st & 2nd line• Example : Cyclosporine 3-5 mg/kg/day, tacrolimus, methotrexate, cyclophosphamide, mycophenolate mofetil dan intravenous Ig.
Acute urticaria better prognosis because the causes can be resolved quickly.
Chronic urticaria is more difficult to overcome because the cause is difficult to find
PROGNOSIS
Urticaria also called ‘nettle-rash’ or ‘hives’ simply means itching with rash.
It usually caused by an allergic reaction, appear as redness with little edema firmly bounded arising quickly after triggered by factors of precipitation and slowly disappear.
CONCLUSION
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