Urticaria, popularly known in Turkish as "kurdeşen", can be defined as an allergic skin rash. Urticaria is divided into acute and chronic. Urticaria lasting up to six weeks is called acute; urticaria lasting more than 6 weeks is called chronic urticaria. However, acute attacks may also occur from time to time over the years.
It is an allergic disease presenting with well-defined, pink-red, raised, itchy, oedematous papules and plaques that disappear within 24 hours. Urticaria has been known since the time of Hippocrates. The term is accepted as being derived from "Urtica urens", the stinging nettle, which causes redness and itching when touched. Urticaria is a disease characterised by papules and plaques with the features of itching, reddening, swelling and disappearing. With or without angioedema, people have a 15–25% chance of having an attack of urticaria at some stage of their life. 30% of cases become chronic. It affects all races and both sexes. Acute urticaria is generally seen in children and young adults, while chronic urticaria more often affects adults, especially women.
Symptoms
Within 24 hours, urticaria itches, reddens, swells and disappears. The urticarial papule (erythema–oedema) is located in the epidermis and papillary dermis. In angioedema, the lower part of the dermis and the subcutis are involved.
The skin signs of urticaria are red, firm raised wheals that can appear anywhere on the body. Their size varies greatly: they may be 1–2 mm or form plaques covering large areas. The wheals are mostly itchy, and the itching gets worse at night. The condition may worsen in the evenings and during menstruation. Rarely, blistering may be seen on them. The lesions usually disappear within 24 hours without leaving any mark.
* Superficial itchy skin rash with a red surround and a pale centre
* Itchy wheals ranging from 2 mm to 30 cm.
* Itching accompanied by a sudden-onset fever.
Types
1. Acute urticaria
In 50% of cases of acute urticaria no cause may be found. Medicines, foods, food additives, implants, contact allergens (acquired through contact) and inhalant allergens (acquired through breathing) may be responsible. The reaction develops within minutes.
Causes of acute urticaria
* Infections
* Medicines and other chemicals
* Foods (nuts, eggs, fish and other seafood, milk, strawberries)
* Insect stings (bees, spiders, insects)
* Spring pollens (flower pollen, poplar pollen)
2. Chronic urticaria
When the symptoms of urticaria last for more than 6 weeks, this is called chronic urticaria. Although the factor causing chronic urticaria is rarely identified, triggering agents are investigated.
Causes of chronic urticaria
Although the cause is hard to find, possible causes include:
* Stress, pressure changes, cold weather, sun and certain exercises
* Certain other skin diseases or systemic diseases outside the skin
* Familial/hereditary diseases
* Continuous intake of the substance causing the allergy
Diagnosis
The clinical diagnostic methods are the same for all types of urticaria. If the red, oedematous rashes cannot be seen, the patient's history helps with the diagnosis.
The duration of the rashes, the presence of systemic (affecting the whole body) complaints and possible aetiological factors are investigated.
Various tests can be used in the diagnosis of urticaria, such as a full blood count, haemogram, erythrocyte sedimentation rate, thyroid function tests, blood biochemistry, complement levels, serum immunoglobulins, serum proteins and electrophoresis, autoantibodies, total IgE and RAST. Skin tests and a search for a focus of infection may also be carried out. In cases resistant to treatment, a biopsy may be taken.
Physical triggers may include pressure, heat, cold, water and sunlight. Special tests exist to identify all of these, but because they carry a risk they must be carried out in a fully equipped hospital.
Treatment
At the treatment stage, the patient should first be given detailed information about their disease. H1 antihistamines are the first line of treatment.
The conditions for successful treatment are questioning the patient about the cause, a good patient–doctor relationship and good follow-up.
Angioedema
- Angioedema is a localised, temporary swelling of the skin or the upper airway and gastrointestinal tract.
- The swelling does not pit when pressed with a finger.
- There is no change in colour, although there may be a slightly erythematous appearance.
- It can be seen anywhere on the body.
- However, it is seen more often in areas where the skin is elastic, such as the face and genital area.
- Angioedema is an emergency and can be life-threatening.
- Failure to diagnose it can delay treatment and, if it occurs in the upper airway, can be fatal.
Clinical features
- About 10% of angioedema cases occur on their own.
- Angioedema is usually accompanied by urticaria.
- This is important for diagnosis and treatment.
Dermographism
Dermographism is a condition accompanied by itching, with linear wheals in the scratched areas that disappear after a short time. It is a type of urticaria (hives). It is seen in 5% of the population. It usually appears suddenly after psychological stress and can continue for many years.
Itching first starts in any part of the person's body; when the person scratches these areas, wheals appear along the lines of the nail marks, the itching gradually spreads and widespread redness develops. It can occur in any area, such as the face, neck, arms or legs. It can be triggered by a hot bath, rubbing dry vigorously with a towel, changing clothes or anything that can cause friction. The itching and wheals usually ease within an hour.
In some people, food and medicine allergies, house dust and pet allergies, intestinal parasites, thyroid diseases and the presence of Helicobacter pylori bacteria in the stomach can also cause dermographism. Attacks of itching followed by wheals can cause distress, especially in social settings.
Antihistamines or leukotriene antagonists are used in treatment. Psychological sedatives may also be added. These medicines are used for at least 3 months and then stopped by gradually reducing the dose over a similarly long period of about 3 months.
Meanwhile, the patient is advised not to eat pickles, hot or spicy foods and nuts. Any medicines that may trigger itching are stopped. Since all medicines, including aspirin, painkillers, blood pressure medicines, contraceptive pills, herbal supplements and vitamin tablets, can be triggers, the patient should inform the dermatologist following them about this.
Pressure Urticaria
Symptoms such as swelling, erythema and pain or burning begin 4–5 hours after pressure or vibration is applied. Pressure urticaria typically appears on the area of skin to which pressure was applied. These areas include places in contact with tight clothing, such as under a waistband or bra straps, the soles of the feet after walking or standing, and the buttocks after sitting.
Cold Urticaria
The symptoms of cold urticaria can be local or systemic and can occur at any age. If the patient is immersed in cold water, a sudden drop in blood pressure may develop (due to intense release of mediators). The disease can be classified as acquired or familial cold urticaria.
Acquired urticaria is more common and may develop after an insect sting, viral infection, drug reaction or childbirth. The diagnosis is made on the basis of the patient's history. In addition, a positive ice test confirms the diagnosis. The ice test involves applying an ice cube to the forearm for 5–10 minutes, assessing whether there is itching within 2 minutes, checking for swelling or redness on the skin that was under the ice, and then allowing the skin to return to its previous temperature within 5–10 minutes.
Cholinergic Urticaria
Cholinergic urticaria, is known as a type of oedematous, itchy condition of the skin. It is also popularly referred to in Turkish as "kurdeşen". The shape and size of cholinergic urticaria can vary. It can look like hundreds of red dots, like measles, or present as large blotches a few centimetres in diameter. Cholinergic urticaria is generally seen around the mouth, around the eyes, on the hands and feet and around the genital area. Normally, with prompt intervention, it is possible to be rid of this condition within a few days. However, if the symptoms keep coming back, it is then defined as an acute condition.
How Does Cholinergic Urticaria Develop?
Cholinergic urticaria, develops when an active structure called the mast cell, when activated in tissues of the body (especially beneath the skin), releases a chemical called histamine, which causes the capillaries where they are located to dilate. As a result of this dilatation, a certain redness and swelling appear in the skin. Unlike fluid-filled blisters, these bumps are firm and take the form of swellings. If this is not treated early, the mast cells may also affect the deeper layers of the skin and lead to more serious consequences.
Cholinergic urticaria, can also be caused by foods or medicines taken into the body. Substances in both foods and medicines can produce allergic effects in some immune systems once they enter the body. With this allergic effect, the mast cells in the body can also be activated. This in turn brings about cholinergic urticaria .
Strophulus
Strophulus is a type of disease showing oedematous papules on the skin. It appears mostly on the arms and legs of children aged 1–3, as pale pink, firm spots ranging in size from a pinhead to a lentil. Papules irritated by scratching may later become inflamed. Unfortunately, the cause of the disease is not yet known; it is regarded as diathetic. That is, substances such as eggs and chocolate are thought to play a part in triggering the disease. The basis of treatment is for such people to avoid, in particular, the foods that do not agree with them. It is also necessary to keep the skin clean, apply aqueous pastes, and give medicines called antihistamines, corticosteroids and calcium.
Polymorphic Eruption of Pregnancy
It is also called pruritic urticarial papules and plaques of pregnancy (PUPPP), toxic erythema of pregnancy and late-onset prurigo of pregnancy. Polymorphic eruption of pregnancy is a benign dermatosis of pregnancy characterised by intensely itchy erythematous papules, plaques and urticarial lesions concentrated in the stretch marks. It is most often seen in women in their first pregnancy and in the third trimester, rarely in the early postpartum period, and it generally does not recur in subsequent pregnancies.
Its incidence ranges from about 1 in 130 to 1 in 300. It is more common in multiple pregnancies (13%) and is associated with multiple pregnancy and excessive maternal weight gain. Although the aetiology of polymorphic eruption of pregnancy is not fully known, the most widely held view is that excessive stretching of the abdominal wall, and the resulting damage to the connective tissue, triggers an immunological response. Apart from the distress the severe itching causes the mother, the prognosis is extremely good. The disease usually does not last more than 6 weeks and resolves on its own.
Early delivery is not thought to affect the duration of the disease. It generally does not recur in later pregnancies, during oral contraceptive use or with menstruation. Clinical features are the most important findings in making the diagnosis. There are no laboratory findings or hormonal changes that differ from those in normal pregnancy.