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HIVES (Urticaria) and Swelling (Angioedema)

Background

 

If normal body chemicals (mostly HISTAMINE) 

are released superficially in the skin, there is 

itching and hives which look like insect bites 

at first..   The location of the hives is usually 

not helpful in the diagnosis unless it is 

beneath a pressure area like a beltline or 

sock line.  If the histamine is released in 

deeper tissue, it usually burns more than 

itches and affects loose tissue such as the 

lips and eyelids. Called angioedemia, it is the 

same basic process as the more typical hives.

  First time urticaria usually lasts less than 4-6

 weeks.   It may affect 15-20% of the general 

population with the woman 35-60  being more

 common in the recurrent form.  

 

Why it happens

Think of histamine release in much the same 

way as you would the common symptom of

 “fever”.   Fever is not a disease, but rather a 

symptom or a “signal” of high immune activity.  

Releasing histamine is the immune system’s 

way of attracting your attention ( works eh?).   If the signal is meaningful and 

reflects major organ problems ( liver, thyroid, 

infection) we uniformly  diagnose it.  If the signal is weak we may not often identify the cause.   If we don’t find a real cause, the symptoms tend to go away on their own ( viral, hormones causes do this) while we cover the symptoms with antihistamines.  If we do find a cause, we will treat the root of the problem.

 

How we work it up:

After a review of your history  a physical exam is completed.   I will be looking for any evidence of even minor infections ( even toenail fungus – tell me). I will also do a limited amount of skin testing for allergy.  Also a small blood sample will be drawn for common medical problems known associated with urticaria.

 

 ( note: the vast majority of this review is extracted from the Medical Clinics of North America May 2004, Volume 24, Number 2, edited by Stephen Dreskin and books edited by Drs. Kaplan and Wanderer, the generally recognized world experts.    


BASIC PRINCIPLE:  LIKE OTHER BODY MESSENGER SYSTEMS INCLUDING FEVER, THIS IS A SYMPTOM – NOT A DISEASE.   LESS THAN 50% OF URTICARIA HAS AN IDENTIFIABLE CAUSE.

 

BACKGROUND AND OVERVIEW:

The name urticaria comes from the name of the stinging nettle plant ( Latin, urtica).  Urticaria was mentioned by the Chinese in the 7th century, then best described by the Englishman James Heberden in 1772 :  “The little elevations upon the skin in the ‘nettle rash’ often appear involuntarily, especially if the skin be rubbed, or scrubbed, and seldom stay many hours in the same place, and sometimes not many minutes. There is no body (part) exempt from “them” and by far the greatest experience no other evil from it besides the intolerable anguish from the itching..”   Hives is the more common term used now.

 

ARE YOU SURE IT IS HIVES ?:

The areas are raised, may be pink or red – or in some cases pale surrounded by a pink flare. They may start as round, from pinpoint to a quarter of an inch – expanding into another to form large wheals. The wheals come and go – sometimes in minutes, sometimes in several hours.  Areas that are painful, last more than 24 hours, leave pigmentary change, form blisters, or look like bruises may suggest another process and should be seen by a dermatologist.

 

HOW MANY PEOPLE SUFFER:

Studies show that 15-25% of the population experience this irritation problem at least once in their lifetime, with women between the age of 30 – 50 years being most commonly affected.  Over a million doctor visits are made each year – you are not alone.   Over half of people with hives also have swelling called angioedemia.Of people with urticaria, 60% have the recurrent variety, 5% have the vasculitic type and 35% have a physical urticaria.


HOW BAD IS IT?

While many people with this problem complain that other people, even doctors, are less than sympathetic, careful surveys reveal that patients with ongoing urticaria have an equally poor quality of life as people with severe heart disease awaiting bypass surgery.   Of 745 medical problems ranked by doctors in priority, ongoing urticaria was listed as 684th – unworthy of funding ( Oregon Health Plan).   This problem is  clearly insignificant – unless you have it personally.  

 

HOW LONG WILL IT LAST?

The prognosis for chronic urticaria is pretty good – it does pass, and most people erroneously feel whatever they were doing last is the reason they are better ( diets, exercise, stress reduction).  50% of people are free I a year, another 20% of people in 5 years – but 10-20% of people battle this for 10-20 years.   Most of the long term folks also have swelling ( angioedemia) – that’s a marker.    


GOOD NEWS: Texas Allergy Experts have been part of an investigation team that brought the new biologic breakthrough for Hives to FDA approval.  We are also doing cutting edge research on newer biologics which may have even better research.    



 

HERES WHAT WE ARE LOOKING FOR AND HOW WE LOOK FOR IT IN TABLES:

 

 

Chronic Urticaria Data

This approach is designed to screen for the most associated neoplasia, mastocystosis, occult inflammation, complement disorders, Autoimmune disease and allergy  with the process of chronic idiopathic urticara

Hematology

RBC

 

 

WBC

 

 

EOS

 

 

Tryptase

 

Inflammation

ALT

 

 

Sinus xr

 

 

CRP

 

Endocrine

TSH

 

Complement

CH50

 

Allergic

IgE

 

 

RAST 0

 

 

RAST1

 

Autoimmune

FcER1

Panel

 

Complement

CH50

 

Allergic

IgE

 

 

RAST 0

 

Physical 

ice cube

 

Autoimmune

FcER1

Panel

 

Testing Procedures for Urticaria and Angioedema

 

Food and drug reactions

Elimination of offending agent, challenge with suspected foods, lamb and rice diet, special diets eliminating natural salicylates and food additives

Inhalant allergens

Skin tests

Collagen vascular diseases

Skin biopsy, CH50, C4, C3, factor B, immunofluorescence of tissue

Malignancy with angioedema

CH50, C1q, C4, Cl-INH determinations

Cold urticaria

Ice cube test

Solar urticaria

Exposure to defined wavelengths of light, red cell protoporphyrin,

Dermographism

Stroking with narrow object (e.g., tongue blade, fingernail)

Pressure urticaria

Application of pressure for defined time and intensity

Aquagenic urticaria

Challenge with tap water at various temperatures

Urticariapigmentosa

Skin biopsy, test for dermographism

Hereditaryangioedema

C4, C2, C1- INH by protein and function

Familial cold urticaria

Challenge by cold exposure, measurement of temperature, white blood cell count, sedimentation rate, and skin biopsy

C3b inactivator deficiency

C3, factor B, C3b inactivator determinations

Autoimmune

FCeR1 antibodies

 

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GENERAL CONSIDERATIONS OF Reasons for urticaria

 

The major causes of urticaria and angioedema that should be considered when any patient is being evaluated are as follows:

1.      Drug reactions

2.      Foods or food additives

3.      Inhalation, ingestion of, or contact with antigens

4.      Transfusion reactions

5.      Infections: bacterial, fungal, viral, and helminthic

6.      Insects (papular urticaria)

7.      Collagen vascular diseases

a.      Cutaneous vasculitis

b.      Serum sickness

8.      Malignancy: angioedema with acquired C1 and C1-inactivator (C1- INH) depletion

9.      Physical urticarias

a.      Cold urticaria

b.      Cholinergic urticaria

c.      Dermographism

d.      Pressure urticaria (angioedema)

e.      Vibratory angioedema

f.       Solar urticaria

g.      Aquagenic urticaria

10.     Urticaria pigmentosa: systemic mastocytosis

11.     Hereditary diseases

a.      Hereditary angioedema

b.      Familial cold urticaria

c.      C3b inactivator deficiency

d.      Amyloidosis with deafness and urticaria

12.     Chronic idiopathic urticaria and chronic angioedema

 

 

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