Forms and complications of urticaria
Urticaria is divided into acute and chronic.
Diagnosis of these forms is based only on the duration of continuous rashes. The limit is 6 weeks of rash.
Acute urticaria , as a rule, does not require any special examinations, with the exception of suspected allergies. In this case, allergy testing with the suspected allergen (eg food) may be required. Most often, acute urticaria is provoked by infections such as ARVI.
If the rash does not stop within 6 weeks, the development of chronic urticaria . Chronic urticaria, in turn, is divided into:
- induced (factors - cold, sun, water or others);
- idiopathic (neither the patient nor the doctor can determine the causes of the rash).
Urticaria or the so-called urticaria-like rash (med. - similar to urticaria) can also be a nonspecific manifestation of some common diseases.
The doctor will help determine the form of the disease and prescribe the necessary examinations and treatment. According to international guidelines (guidelines), numerous and detailed examinations are not carried out for patients with urticaria. If the urticaria is induced, the cause of the rash will be determined at the initial appointment. In most cases, urticaria is idiopathic—it is not caused by diet or lifestyle.
Hives can be one of the manifestations of severe allergic reactions.
In these cases, it occurs simultaneously with symptoms such as swelling (angioedema), shortness of breath and difficulty breathing (bronchospasm), vomiting, diarrhea, decreased blood pressure, lethargy, weakness - even loss of consciousness. In this situation, emergency medical care is necessary.
Symptoms
The rash is very similar in appearance to a nettle burn, which is why it got its name. It develops quickly, blisters of various shapes can grow, merge, appear and disappear on different parts of the body. The rash is not painful, but is usually accompanied by severe itching. After treatment or after eliminating the allergen, the urticaria disappears without a trace, and if the skin has not been scratched, it will look healthy as before. Sometimes the rash can affect the mucous membranes and subcutaneous tissue, which is dangerous due to the possibility of aponeurotic edema, commonly known as Quincke's edema.
Causes of urticaria
Acute, new-onset or chronic induced urticaria may be a reaction to a viral infection, medication, food, exercise, intense sunlight, contact with animals, cosmetics, chemicals (such as latex or nickel), or may be caused by other causes.
Acute urticaria may be one of the manifestations of a parasitic infection. But since, according to WHO, parasite infections are not widespread in our region, when deciding whether to schedule an examination, it is necessary to take into account risk factors and other manifestations of infection (visiting regions with a high risk of becoming infected, eating raw fish or meat, the presence of gastrointestinal complaints). -intestinal tract, blood eosinophilia and others).
Most cases of chronic urticaria have no external causes.
Under the influence of external factors or without external causes, histamine and other substances are released from mast cells, swelling and itching of the skin begins, and rashes appear. Isolation can be caused by different types of immunological reactions. These may be allergic reactions, reactions caused by the influence of complement or immune complexes. Chronic urticaria is usually associated with autoimmune reactions, but there is no reliable test to accurately determine this.
Clinic
Chronic urticaria is a disease whose clinical course is difficult to predict. In some cases, chronic urticaria may resolve spontaneously. The average duration of the disease is from 2 to 5 years. Within 1 year, spontaneous remission occurs in approximately 30–50% of patients in whom the cause of urticaria is not determined. Symptoms of the disease persist for 5 years or more in approximately 1/5 of patients [8].
Let's consider the clinical manifestations of various forms of chronic urticaria.
Dermographic urticaria is the most common form of urticaria, the symptoms of which develop under the influence of physical factors, and is observed in approximately 5% of individuals in the general population [9]. In this case, persistent dermographism can develop against the background of relatively light pressure, friction, or even stroking, for example, caused by friction or contact of trousers, cuffs, or collars with the skin. As a rule, with this form of the disease, the blisters disappear spontaneously within a few minutes after the cessation of exposure to the causative factor.
Cold urticaria is the second most common type of physical urticaria, characterized by the appearance of urticaria on the skin of patients under the influence of cold air, liquids, and solids and develops more often in women. It should be noted that contact with the cold environment of large areas of the skin, for example when swimming in cold water, can provoke in patients with this type of urticaria the development of systemic symptoms, such as shortness of breath, hypotension, loss of consciousness, which in some cases can lead to death .
Retrospective studies have shown that the average temperature threshold for the development of symptoms of cold urticaria is 13.7±6.0 °C [10]. It is noted that the development of this type of urticaria may be associated with the presence of concomitant viral, bacterial and parasitic infections, IgG cryoglobulinemia or cryoglobulinemia of mixed type IgG/IgM and IgG/IgA, hymenoptera insect bites, intolerance to certain foods and medications, low levels of C1 inhibitors and C4, as well as changes in the levels of a number of chemokines in the peripheral blood [11].
Heat urticaria is a very rare variant of physical urticaria and manifests as limited erythema and blistering that usually persists for 1–3 hours immediately after local heat application to the skin.
Urticaria, which develops under the influence of pressure, is angioedema in areas of the skin and mucous membrane that have been subjected to compression. In this case, painful swelling of the skin, itching or burning occurs several hours after mechanical impact on the skin and can persist from several hours to 1 day or more. As a rule, this type of urticaria occurs against the background of wearing tight, tight-fitting clothes and shoes, heavy backpacks or bags with shoulder straps, sitting or lying on a hard surface. Pressure-induced urticaria often coexists with other types of chronic urticaria. At the same time, this variant of the disease should be distinguished from symptomatic dermographism, in which swelling and local swelling of the skin may occur, for example, when wearing belts. However, these symptoms are present on the skin for a short time and, as a rule, are not accompanied by subjective sensations.
Solar urticaria in most cases develops due to exposure of the skin to sunlight, but not to ultraviolet radiation from an artificial source. This type of urticaria is relatively rare, accounting for 0.08% of all patients with urticaria and 2.3% of patients with photodermatoses. In this case, women and people with concomitant diseases of atopic nature are more likely to get sick [12].
Cholinergic urticaria develops against a background of increased body temperature, for example caused by exercise, fever, a hot bath, psycho-emotional stress, or ingestion of hot or spicy foods and drinks. This type of urticaria is most often observed in young patients and during the cold season. A connection has been found between cholinergic urticaria and atopy and bronchial hyperreactivity [13].
A distinctive sign of cholinergic urticaria is the appearance of small (diameter up to 5–6 mm), itchy, quickly disappearing blisters on the skin. These symptoms are associated with the absence of acetylcholinesterase in the epithelial cells of the eccrine glands and a decrease in the expression of cholinergic receptors M3 (CHRM3), probably as a result of the development of autoimmune reactions to eccrine sweat glands and/or acetylcholine receptors, leading to an increase in tissue levels of acetylcholine, stimulating mast cell degranulation [14]. In addition, the cause of the development of this variant of chronic urticaria is considered to be an increase in histamine levels, the development of an allergic reaction to sweat components, serum factors, oral occlusion of eccrine sweat glands and anhidrosis.
Vibration urticaria is a very rare variant of physical urticaria, which is angioedema that develops against the background of exposure to local vibration. Vibratory angioedema can be induced by snoring or dental procedures [15].
Contact urticaria develops through direct contact with a provoking substance and is manifested by the immediate appearance of blisters in the area of influence of the causative factor, which disappear within a few hours. In some cases, skin rashes can spread and cause systemic reactions that pose a risk to the patient's life. Repeated contact with the etiological factor can lead to the development of dermatitis/eczema.
The most common causes of contact urticaria are food, plant components (especially juice, plant leaves), latex, components of cosmetics, industrial chemicals, and products made from natural fibers of animal origin. Thus, contact urticaria is a common pathology in general clinical practice, and in some cases it can be recognized as an occupational skin disease, for example in the food industry, healthcare, etc.
Aquagenic urticaria is a rare variant of the disease and a kind of symbiosis of physical and contact urticaria. With this type of disease, patients develop folliculocentric blisters with a diameter of up to 1–3 mm on the skin, prone to coalescence, within 20–30 minutes after skin contact with water, sweat or tears [16]. Favorite locations for rashes are the torso and shoulders, while the palms and soles are usually free of rashes.
Aquagenic urticaria has a strong negative impact on the quality of life, since in the modern world it is impossible to exclude contact with water and limit the implementation of simple hygiene procedures.
Treatment of urticaria in adults and children
The main group of drugs for the treatment of both acute and chronic urticaria are histamine type I receptor blockers (antihistamines). In accordance with the international recommendations of GA2LEN, it is possible to combine different drugs or increase the dose of an antihistamine (in our country, an increased dose of antihistamines is not officially registered).
For severe exacerbations, short-term use of corticosteroid hormones is possible. This treatment does not affect the prognosis of the disease, but can quickly reduce severe and pronounced symptoms.
If the effect of antihistamines (at the maximum dose) is insufficient in the treatment of chronic urticaria, it is possible to prescribe antileukotriene drugs and type II histamine receptor blockers. And in severe cases - biological therapy with the drug omalizumab or immunosuppressive therapy with cyclosporine.
Features of the treatment method for urticaria
Even with significant itching, a large area of rash and a long (sometimes many years) course, chronic urticaria does not lead to changes in the internal organs. In most cases, it gradually (sometimes over several years or even decades) stops.
The main task of the doctor here is to maintain a comfortable quality of life for the patient, determine the possible causes of the disease and monitor to identify other diseases with similar rashes.
Drugs for the treatment of severe forms of urticaria
Omalizumab is an antibody to immunoglobulin E and is used for severe chronic idiopathic urticaria and bronchial asthma. Before prescribing the drug, the doctor will conduct an examination and make sure that simpler methods of treatment were ineffective. The drug is administered subcutaneously once every 4 weeks. Treatment is carried out on an outpatient basis, but always under the supervision of a doctor. The drug is generally well tolerated and side effects are rare. The downside is the high cost of treatment.
Cyclosporine is another drug that is prescribed for severe chronic idiopathic urticaria. Belongs to a group of drugs that reduce the body's immunological reactions and therefore have an anti-inflammatory effect. In addition to the treatment of chronic urticaria, it is used in dermatology to treat severe forms of atopic dermatitis, psoriasis and some other diseases. Before starting treatment and during treatment, it is necessary to monitor the condition of the body; the doctor will conduct an examination and make sure that simpler methods of treatment were ineffective.
How is urticaria treated at the Rassvet clinic?
In order to prescribe the necessary treatment, your dermatologist will examine your skin and ask questions about your condition.
It is important to tell your doctor what factors you feel are causing your condition to worsen; what treatment did you receive before, was it effective; which medications worked best and which had no effect.
The diagnosis of urticaria is established based on a doctor’s examination; there are no specific laboratory diagnostic tests. Additional research may be required to clarify the form of the disease. If your doctor has doubts about whether your condition fits the diagnosis of urticaria, a diagnostic skin biopsy (taking a piece of skin) and histological examination (examining the resulting material under a microscope) may be necessary.
Finding medications to control the disease may take some time. First, small doses of drugs are prescribed, then they are gradually increased. After achieving stable improvement, treatment should be continued; in the future, the dose of prescribed medications can be gradually reduced until completely discontinued.
Recommendations of a dermatologist for patients with urticaria
Advice for patients:
- Seek immediate medical help if you experience rapid or difficult breathing, nausea, vomiting, abdominal pain, or loss of consciousness;
- exclude trigger factors (factors that cause deterioration) that you are reliably aware of, foods to which you have a proven allergy.
The prescription of a diet for chronic urticaria is controversial. The benefit of a diet avoiding pseudoallergens or histamine-containing foods in the treatment of chronic urticaria has not been proven by research. Following such diets poses significant challenges and is not supported by most current clinical guidelines.
Author:
Voronina Vera Removna dermatologist
