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Introduction:
UrticariaandAngioedemaUrticariaAngioedemaIntroduction:
UrticariaandAnEtiologyofUrticarialReactions:
AllergicTriggersAcuteUrticariaDrugsFoodsFoodadditivesViralinfectionshepatitisA,B,CEpstein-BarrvirusInsectbitesandstingsContactantsandinhalants
(includesanimaldanderandlatex)ChronicUrticariaPhysicalfactorscoldheatdermatographicpressuresolarIdiopathicEtiologyofUrticarialReactioThePathogenesisofChronicUrticaria:
CellularMediatorsThePathogenesisofChronicUrHistamineasaMastCellMediatorHistamineasaMastCellMediaRoleofMastCellsinChronicUrticaria:
LowerThresholdforHistamineReleaseReleasethresholddecreasedby:Cytokines&chemokines
inthecutaneous
microenvironmentAntigenexposureHistamine-releasingfactorAutoantibodyPsychologicalfactorsReleasethresholdincreasedby:CorticosteroidsAntihistaminesCromolyn(invitro)CutaneousmasscellRoleofMastCellsinChronicAnAutoimmuneBasisforChronic
IdiopathicUrticaria:AntibodiestoIgEAnAutoimmuneBasisforChroniInitialWorkupofUrticariaPatienthistorySinusitisArthritisThyroiddiseaseCutaneousfungalinfectionsUrinarytractsymptomsUpperrespiratorytractinfection
(particularlyimportantinchildren)Travelhistory(parasiticinfection)SorethroatEpstein-Barrvirus,infectious
mononucleosisInsectstingsFoodsRecenttransfusionswith
bloodproducts(hepatitis)RecentinitiationofdrugsPhysicalexamSkinEyesEarsThroatLymphnodesFeetLungsJointsAbdomenInitialWorkupofUrticariaPatLaboratoryAssessmentfor
ChronicUrticariaPossibletestsforselectedpatientsStoolexaminationforova
andparasitesBloodchemistryprofileAntinuclearantibodytiter(ANA)HepatitisBandCSkintestsforIgE-mediated
reactionsInitialtestsCBCwithdifferentialErythrocytesedimentationrateUrinalysisRASTforspecificIgEComplementstudies:CH50CryoproteinsThyroidmicrosomalantibodyAntithyroglobulinThyroidstimulatinghormone(TSH)LaboratoryAssessmentfor
ChrHistopathologyGroup2:PolymorphousperivascularinfiltrateNeutrophilsEosinophilsMononuclearcellsGroup3:SparseperivascularlymphocytesHistopathologyGroup2:Group3:UrticariaAssociatedWith
OtherConditionsCollagenvasculardisease(eg,systemiclupuserythematosus)Complementdeficiency,viralinfections(includinghepatitisB
andC),serumsickness,andallergicdrugeruptionsChronictineapedisPruriticurticarialpapulesandplaquesofpregnancy(PUPPP)Schnitzler’ssyndromeUrticariaAssociatedWith
OthH1-ReceptorAntagonists:
ProsandConsforUrticariaandAngioedemaFirst-generationantihistamines(diphenhydramine
andhydroxyzine)Advantages:Rapidonsetofaction,relativelyinexpensiveDisadvantages:Sedating,anticholinergicSecond-generationantihistamines(astemizole,
cetirizine,fexofenadine,loratadine)Advantages:Nosedation(exceptcetirizine);noadverse
anticholinergiceffects;bidandqddosingDisadvantages:ProlongationofQTinterval;ventricular
tachycardia(astemizoleonly)inapatientsubgroupH1-ReceptorAntagonists:
ProsFour-weekTreatmentPeriod:
FexofenadineHClMeanPruritusScores/MeanNumberofWheals/MeanTotalSymptomScoresFour-weekTreatmentPeriod:
FeAnApproachtotheTreatmentof
ChronicUrticariaAnApproachtotheTreatmentoTreatmentofUrticaria:
PharmacologicOptionsAntihistamines,othersFirst-generationH1Second-generationH1Antihistamine/decongestant
combinationsTricyclicantidepressants
(eg,doxepin)CombinedH1andH2agentsBeta-adrenergicagonistsEpinephrineforacuteurticaria
(rapidbutshort-livedresponse)TerbutalineCorticosteroidsSevereacuteurticariaavoidlong-termuseusealternate-dayregimen
whenpossibleAvoidinchronicurticaria
(lowestdoseplusantihistamines
mightbenecessary)MiscellaneousPUVAHydroxychloroquineThyroxineTreatmentofUrticaria:
PharmAtopicDermatitis:Acute,Subacute,
andChronicLesionsAcuteCutaneousLesionsErythematous,intenselypruriticpapulesandvesiclesConfinedtoareasofpredilectioncheeksininfantsantecubitalpoplitealSubacuteCutaneousLesionsErythemaexcoriation,scalingBleedingandoozinglesionsChronicLesionsExcoriationswithcrustingThickenedlichenifiedlesionsPostinflammatoryhyperpigmentationNodularprurigoAtopicDermatitis:Acute,SubaAtopicDermatitis:
PhysicalDistributionbyAgeGroupAtopicDermatitis:
PhysicalDImmuneResponseinAtopicDermatitisMarkedlyelevatedserumIgElevelsPeripheralbloodeosinophiliaHighlycomplexinflammatoryresponses>IgE-dependent
immediatehypersensitivityMultifunctionalroleofIgE(beyondmediationofspecific
mastcellorbasophildegranulation)CelltypesthatexpressIgEonsurfacemonocyte/macrophagesLangerhans’cellsmastcellsbasophilsImmuneResponseinAtopicDermAtopicDermatitis:
TeststoIdentifySpecificTriggersSkinpricktestingforspecificenvironmental
and/orfoodallergensRAST,ELISA,etc,toidentifyserumIgEdirectedtospecific
allergensinpatientswithextensivecutaneousinvolvementTzancksmearforherpessimplexKOHpreparationfordermatophytosisGram’sstainforbacterialinfectionsCultureforantibioticsensitivityforstaphylococcalinfection;
supplementwithbacterialculturesCulturestosupporttestsbacterial,viral,orfungalAtopicDermatitis:
TeststoIdTopicalCorticosteroidsRankedfromhightolowpotencyin7classesGroup1(mostpotent):betamethasonedipropionate0.05%Group4(intermediatepotency):hydrocortisonevalerate0.2%Group7(leastpotent):hydrocortisonehydrochloride1%Localsideeffects:
Developmentofstriaeandatrophyoftheskin,perioral
dermatitis,rosaceaSystemiceffects:
Dependonpotency,siteofapplication,occlusiveness,
percentageofbodycovered,lengthofuseMaycauseadrenalsuppressionininfantsandsmallchildren
ifusedlongtermTopicalCorticosteroidsRankedAntihistaminesandOtherTreatmentsStandardTreatmentOralantihistaminestorelieveitchingMoisturizertominimizedryskinTopicalcorticosteroidsHard-to-manageDiseaseAntibioticsCoaltarpreparations(antipruriticandanti-inflammatory)WetdressingsandocclusionSystemiccorticosteroidsUVlighttherapyHospitalizationAntihistaminesandOtherTreatIntroduction:
UrticariaandAngioedemaUrticariaAngioedemaIntroduction:
UrticariaandAnEtiologyofUrticarialReactions:
AllergicTriggersAcuteUrticariaDrugsFoodsFoodadditivesViralinfectionshepatitisA,B,CEpstein-BarrvirusInsectbitesandstingsContactantsandinhalants
(includesanimaldanderandlatex)ChronicUrticariaPhysicalfactorscoldheatdermatographicpressuresolarIdiopathicEtiologyofUrticarialReactioThePathogenesisofChronicUrticaria:
CellularMediatorsThePathogenesisofChronicUrHistamineasaMastCellMediatorHistamineasaMastCellMediaRoleofMastCellsinChronicUrticaria:
LowerThresholdforHistamineReleaseReleasethresholddecreasedby:Cytokines&chemokines
inthecutaneous
microenvironmentAntigenexposureHistamine-releasingfactorAutoantibodyPsychologicalfactorsReleasethresholdincreasedby:CorticosteroidsAntihistaminesCromolyn(invitro)CutaneousmasscellRoleofMastCellsinChronicAnAutoimmuneBasisforChronic
IdiopathicUrticaria:AntibodiestoIgEAnAutoimmuneBasisforChroniInitialWorkupofUrticariaPatienthistorySinusitisArthritisThyroiddiseaseCutaneousfungalinfectionsUrinarytractsymptomsUpperrespiratorytractinfection
(particularlyimportantinchildren)Travelhistory(parasiticinfection)SorethroatEpstein-Barrvirus,infectious
mononucleosisInsectstingsFoodsRecenttransfusionswith
bloodproducts(hepatitis)RecentinitiationofdrugsPhysicalexamSkinEyesEarsThroatLymphnodesFeetLungsJointsAbdomenInitialWorkupofUrticariaPatLaboratoryAssessmentfor
ChronicUrticariaPossibletestsforselectedpatientsStoolexaminationforova
andparasitesBloodchemistryprofileAntinuclearantibodytiter(ANA)HepatitisBandCSkintestsforIgE-mediated
reactionsInitialtestsCBCwithdifferentialErythrocytesedimentationrateUrinalysisRASTforspecificIgEComplementstudies:CH50CryoproteinsThyroidmicrosomalantibodyAntithyroglobulinThyroidstimulatinghormone(TSH)LaboratoryAssessmentfor
ChrHistopathologyGroup2:PolymorphousperivascularinfiltrateNeutrophilsEosinophilsMononuclearcellsGroup3:SparseperivascularlymphocytesHistopathologyGroup2:Group3:UrticariaAssociatedWith
OtherConditionsCollagenvasculardisease(eg,systemiclupuserythematosus)Complementdeficiency,viralinfections(includinghepatitisB
andC),serumsickness,andallergicdrugeruptionsChronictineapedisPruriticurticarialpapulesandplaquesofpregnancy(PUPPP)Schnitzler’ssyndromeUrticariaAssociatedWith
OthH1-ReceptorAntagonists:
ProsandConsforUrticariaandAngioedemaFirst-generationantihistamines(diphenhydramine
andhydroxyzine)Advantages:Rapidonsetofaction,relativelyinexpensiveDisadvantages:Sedating,anticholinergicSecond-generationantihistamines(astemizole,
cetirizine,fexofenadine,loratadine)Advantages:Nosedation(exceptcetirizine);noadverse
anticholinergiceffects;bidandqddosingDisadvantages:ProlongationofQTinterval;ventricular
tachycardia(astemizoleonly)inapatientsubgroupH1-ReceptorAntagonists:
ProsFour-weekTreatmentPeriod:
FexofenadineHClMeanPruritusScores/MeanNumberofWheals/MeanTotalSymptomScoresFour-weekTreatmentPeriod:
FeAnApproachtotheTreatmentof
ChronicUrticariaAnApproachtotheTreatmentoTreatmentofUrticaria:
PharmacologicOptionsAntihistamines,othersFirst-generationH1Second-generationH1Antihistamine/decongestant
combinationsTricyclicantidepressants
(eg,doxepin)CombinedH1andH2agentsBeta-adrenergicagonistsEpinephrineforacuteurticaria
(rapidbutshort-livedresponse)TerbutalineCorticosteroidsSevereacuteurticariaavoidlong-termuseusealternate-dayregimen
whenpossibleAvoidinchronicurticaria
(lowestdoseplusantihistamines
mightbenecessary)MiscellaneousPUVAHydroxychloroquineThyroxineTreatmentofUrticaria:
PharmAtopicDermatitis:Acute,Subacute,
andChronicLesionsAcuteCutaneousLesionsErythematous,intenselypruriticpapulesandvesiclesConfinedtoareasofpredilectioncheeksininfantsantecubitalpoplitealSubacuteCutaneousLesionsErythemaexcoriation,scalingBleedingandoozinglesionsChronicLesionsExcoriationswithcrustingThickenedlichenifiedlesionsPostinflammatoryhyperpigmentationNodularprurigoAtopicDermatitis:Acute,SubaAtopicDermatitis:
PhysicalDistributionbyAgeGroupAtopicDermatitis:
PhysicalDImmuneResponseinAtopicDermatitisMarkedlyelevatedserumIgElevelsPeripheralbloodeosinophiliaHighlycomplexinflammatoryresponses>IgE-dependent
immediatehypersensitivityMultifunctionalroleofIgE(beyondmediationofspecific
mastcellorbasophildegranulation)CelltypesthatexpressIgEonsurfacemonocyte/macrophagesLangerhans’cellsmastcellsbasophilsImmuneResponseinAtopicDermAtopicDermatitis:
TeststoIdentifySpecificTriggersSkinpricktestingforspecificenvironmental
and/orfoodallergensRAST,ELISA,etc,toidentifyserumIgEdirectedtospecific
alle
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