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Explore different types of urticaria and effective management strategies with Meri Sehat. Prioritize skin health

Types Of Urticaria And How To Manage Them

Urticaria, commonly known as hives, is a skin condition characterized by itchy, raised, and often red welts on the skin. It can be caused by various factors, including allergies, infections, medications, stress, and even temperature changes. Urticaria can occur anywhere on the body and may vary in size and shape. The welts typically appear suddenly and may come and go within a few hours or days. Although urticaria is generally harmless and resolves on its own, it can be quite uncomfortable and distressing for those affected. Treatment options include antihistamines, corticosteroids, and identifying and avoiding triggers. If you experience severe symptoms or if the hives persist for more than six weeks, it is advisable to seek medical attention for a proper diagnosis and management plan. Remember, understanding the causes and triggers of urticaria can greatly help in preventing future outbreaks and promoting overall skin health.

Introduction

<a href="https://merisehat.pk/disease/urticaria">Urticaria</a> is the medical term for &ldquo;hives.&rdquo; It is also known as wheals, welts, and nettle rash<a href="#accordion">[6]</a>.&nbsp; The condition is named after the stinging nettle Urtica dioica. It can be induced or spontaneous, acute or chronic<a href="#accordion">[7]</a>. 
&nbsp;

The lifetime prevalence of urticaria is roughly 20%, making it one of the most prevalent skin conditions<a href="#accordion">[1]</a>.&nbsp;Individual wheals vary widely in size, quantity, and appearance.

The need for correct identification and categorisation of the various types of urticaria stems from the fact that it helps doctors select an effective treatment plan. Moreover, it helps improve the quality of life, preserve occupational and academic ability, and reduce any potential side effects for the patient. 
&nbsp;

Understanding the Management of Different Types of Urticaria

&nbsp;Currently, there are numerous international classifications of urticaria based on specialised research and the multiple origins of the condition that makes classification complicated and challenging.

The recent European guidelines state that clinical presentations are heterogeneous and that they can be classified into 3 broad categories<a href="#accordion">[10]</a>:

<ol>
	<li>Spontaneous</li>
	<li>Physical</li>
	<li>Special types of urticaria 
	&nbsp;</li>
</ol>

About 70-80% cases of urticaria are spontaneous<a href="#accordion">[14]</a>.

It is conceivable for a patient to have 2 or even multiple subtypes at once. For example, spontaneous chronic urticaria combined with dermatographic urticaria or spontaneous chronic urticaria combined with delayed pressure urticaria. In these circumstances, urticaria is typically persistent and challenging to treat. 
&nbsp;

Acute (allergic or non-allergic) spontaneous urticaria makes up around two-thirds of the condition, while one-third of the patients are chronically ill<a href="#accordion">[11]</a>.&nbsp;Nearly 40-50% of patients with spontaneous urticaria also experienced angioedema<a href="#accordion">[12]</a>. 
&nbsp;

<ul>
	<li>
	Acute Urticaria is described as the occurrence of spontaneous wheals that lasts less than 6 weeks; it&rsquo;s usually for 1-2 weeks.
	</li>
	<li>Chronic Urticaria, which has a lifetime prevalence of 0.5% (mostly in middle-aged women), occurs over the course of more than 6 weeks with daily attacks. It can also be episodic (intermittent), i.e., patients will have fewer attacks of urticaria that last for a longer period of time. 
	&nbsp;</li>
</ul>

The typical duration of chronic urticaria is 3-5 years; however, longer courses of up to 20 years are also seen. Pruritus, sleep difficulties, and additional psychosocial issues all noticeably impair the quality of life. 
&nbsp;

Also known as chronic inducible urticaria (CIndU), these hives are brought on by direct physical stimulation of the skin, like sweating or vibration, cold, pressure, and exercise. These hives often develop wherever the skin has been affected, with most of them starting to appear within an hour of exposure.

The majority of physical urticaria types last for 3-5 years or longer than that. The healthcare practitioner will ask for in-depth medical history, a clinical examination, and objective physical testing in order to make the diagnosis. 
&nbsp;

<ol>
	<li>
	<h5>Dermatographism</h5>
	</li>
</ol>

Within a few minutes, dermatographic urticaria appears at the location where the skin receives pressure or trauma. The term literally means &ldquo;writing on the skin&rdquo;. 
&nbsp;

Sign &amp; Symptoms

Asymptomatic urticaria dermographism has little clinical importance. The most typical type of physical urticaria is demographic urticaria, which normally lasts 6.5 years. It is characterised by linear hives that itch intensely. 
 
Causes

Hives develop after abrasive skin touching or scratching. These hives can also coexist with different urticaria types.

 
Treatment

The foundation of treatment, similar to sudden chronic urticaria, is a sufficient daily dose of second-generation H1 antihistamines; sometimes, it increases and goes up to 4 times or higher the recommended dosage<a href="#accordion">[13]</a>. 
&nbsp;

<ol start="2">
	<li>
	<h5>Delayed Pressure Urticaria</h5>
	</li>
</ol>

Delayed pressure urticaria occurs when the hives are kind of deep and more painful than itchy swellings. They appear about 6-8 hours after vertical pressure and can last up to 2 days.

The skin under bra straps or belts, the back, the hips, and the palms and soles are frequently affected. A variety of stimuli, such as tight clothing, standing, or sitting on a hard surface, can all be responsible for these lesions. They are also, at times, aggravated by menstruation and heat.

Compared to other urticaria types, delayed pressure urticaria mostly affects middle-aged males. 
&nbsp;

Signs &amp; Symptoms

Leukocytosis, arthralgias, myalgias, and weariness are some of the symptoms that are usually present in delayed pressure urticaria. Additionally, this condition often lasts 6-9 years and can be occupationally disruptive. 
&nbsp;

Diagnostic Procedure

Standard test involves applying a weight of 0.5-1.5 kg/cm2 for 10 mins at various places (back, ventral, and dorsal thigh). If definite raised wheals occur after a few hours, it indicates delayed pressure urticaria. For that purpose, it&rsquo;s important to evaluate the site after 30 mins, and at 3-, 6-, and 24-hours intervals. Any lesions that last more than 24 hours have to be biopsied to rule out vasculitis<a href="#accordion">[8]</a>.

Pressure-aggravated spontaneous chronic urticaria, i.e., when hives are provoked due to pressure (e.g., tight clothing) but do not always occur subsequently, is a differential diagnostic factor since erythema or hives usually develop after only 30 minutes in standardised physical exams. 
&nbsp;

Treatment

Although antihistamines frequently fail to control delayed pressure urticaria &ndash; even at higher doses &ndash; they are still considered the first line of treatment. Medium- to low-dose glucocorticoids (e.g., 40 mg, 20 mg, or less) can also be beneficial for some patients, although these should only be used on an ongoing basis.

Dapsone (100&ndash;150 mg per day) can be effective in treating delayed pressure urticaria. Methotrexate (15 mg/week), montelukast, ketotifen plus nimesulide, sulfasalazine, or topical clobetasol propionate 0.5% are other potential substitutes that have proven to be effective in single case reports<a href="#accordion">[9]</a>. 
&nbsp;

<ol start="3">
	<li>
	<h5>Cold Urticaria</h5>
	</li>
</ol>

In young adults, acquired cold urticaria typically manifests within minutes of contact with cold items or water. However, it can also occur with cold air and, less frequently, with cold foods and beverages. An average duration is 5 years. 
&nbsp;

Diagnostic Procedure 

The optimal way to carry out diagnostically standardised cold testing is to identify the temperature threshold that causes symptoms. For example, using cold arm baths at set temperatures.

Other than that, cryoglobulins (special proteins for disease condition diagnostics), cold agglutinins (antibodies that recognise antigens on RBCs at temperatures below normal core body temperature), and cryofibrinogen (an atypical protein that precipitates only in plasma) can be investigated. 
&nbsp;

Treatment 

Even if they are frequently unable to suppress symptoms, H1 antihistamines of the more recent generation are the first line of treatment. Complete or partial remission can result from long (approximately 3&ndash;4 weeks) antibiotic treatment, such as oral doxycycline or intramuscular penicillin. There&rsquo;s little evidence regarding the effectiveness of cyproheptadine, ketotifen, or montelukast to treat these cases. 
&nbsp;

<ol start="4">
	<li>
	<h5>Localised Heat Contact Urticaria</h5>
	</li>
</ol>

After coming into direct touch with warm water, warm air, or warm objects (temperatures between 38 and 50 &deg;C), small, transient hives commonly appear in the localised heat contact urticaria. The temperature threshold should ideally be established through standardised physical heat testing. Due to its rarity, evidence-based therapy does not exist. Doctors may recommend hydroxy-chloroquine or tolerance induction. 
&nbsp;

<ol start="5">
	<li>
	<h5>Solar Urticaria</h5>
	</li>
</ol>

Solar urticaria (light urticaria) accounts for roughly 4% of all photosensitive dermatoses<a href="#accordion">[8]</a>. It often affects women in their 30s or 40s. While UV light is the main stimulus to induce solar urticaria, wavelengths between 280 and 760 nm have also been identified. Individual hives in solar urticaria tend to last between 15 minutes to 3 hours. 
&nbsp;

Diagnosis

A 10-minutes exposure to specific wavelengths of a monochromator, such as a slide projection (visible light), can help ascertain the minimum urticarial dosage that provokes a reaction. Possible differential diagnoses include polymorphic light eruption and lupus erythematosus<a href="#accordion">[16]</a>. 
&nbsp;

Treatment 

Despite being the preferred therapy, H1 antihistamines frequently fail to provide relief to patients with solar urticaria. In addition to photo hardening, options include intravenous immunoglobulins, plasma exchange, photopheresis, and cyclosporin<a href="#accordion">[17]</a>. 
&nbsp;

<ol start="6">
	<li>
	<h5>Vibratory Urticaria</h5>
	</li>
</ol>

Urticaria or angioedema, in rare instances, is caused by vibratory forces, such as using a pneumatic hammer or riding a bicycle over cobblestones. Such vibratory stimulation ought to be avoided in therapeutic settings. 
&nbsp;

Conclusion

It&rsquo;s important to first identify the type of urticaria for proper diagnoses and appropriate treatment. In almost all cases, the first preference of treatment is H1 antihistamines to deal with the allergic response. Complete remission is possible from long-term antibiotic therapy, such as intramuscular penicillin or oral doxycycline. However, always consult a skin care specialist (dermatologist) for urticaria management. 
&nbsp;

Key Takeaways

<ul>
	<li>Urticaria or hives appear due to stimulation of the skin by factors including cold, heat, sunshine, vibration, pressure, sweat, and exercise.</li>
	<li>The hives usually linger for 2 hours or less, except when it&rsquo;s a case of delayed pressure urticaria.</li>
	<li>The most typical kind of physical urticaria is demographic urticaria, which lasts 6.5 years on average.</li>
	<li>These hives may also coexist with other forms of urticaria.</li>
	<li>In almost all cases, the first preference of treatment is H1 antihistamines to deal with the allergic response.</li>
	<li>Palms and soles, hips, the back, and the skin beneath bra straps or belts are frequently affected regions.</li>
	<li>Always consult a skin care specialist (dermatologist) for urticaria management.</li>
</ul>

[1] Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Gimenez-Arnau A, et al. EAACI/GA2LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. 2009;64(10):1417–26.

[2] Wedi B. Urtikaria und Angioödem. In: Braun-Falco’s Dermatologie, Venerologie und Allergologie. Springer; 2018. p. 475–501.

[3] Bork K, Meng G, Staubach P, Hardt J. Hereditary angioedema: new findings concerning symptoms, affected organs, and course. Am J Med. 2006;119(3):267–74.

[4] Wedi B, Novacovic V, Koerner M, Kapp A. Chronic urticaria serum induces histamine release, leukotriene production, and basophil CD63 surface expression—inhibitory effects of anti-inflammatory drugs. J Allergy Clin Immunol. 2000;105(3):552–60.

[5] Kontou-Fili K, Borici-Mazi R, Kapp A, Matjevic LJ, Mitchel FB. Physical urticaria: classification and diagnostic guidelines: an EAACI position paper. Allergy. 1997;52(5):504–13.

[6] Hives (urticaria): Causes, pictures, treatments, and symptoms. Medical News Today.

[7] Urticaria – an overview. DermNet.

[8] Allergy and asthma. Google Books.

[9] Clinical dermatology E-book. Google Books.

[10] Zuberbier T. Classification of urticaria. Indian journal of dermatology.

[11] Urticaria. Allergy and Immunology - Diseases - McMaster Textbook of Internal Medicine South Asian Ed.

[12] Sánchez-Borges M, Asero R, Ansotegui IJ, et al. Diagnosis and treatment of urticaria and angioedema: A worldwide perspective. The World Allergy Organization journal.

[13] van den Elzen MT, van Os-Medendorp H, van den Brink I, et al. Effectiveness and safety of antihistamines up to fourfold or higher in treatment of chronic spontaneous urticaria - clinical and translational allergy. BioMed Central.