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URTICARIA

Urticaria (or hives) is a skin condition, commonly caused by an allergic reaction, that is characterized by raised red skin wheals (welts). It is also known as nettle rash or uredo. Wheals from urticaria can appear anywhere on the body, including the face, lips, tongue, throat, and ears. The wheals may vary in size from about 5 mm (0.2 inches) in diameter to the size of a dinner plate; they typically itch severely, sting, or burn, and often have a pale border. Urticaria is generally caused by direct contact with an allergenic substance, or an immune response to food or some other allergen, but can also appear for other reasons, notably emotional stress. The rash can be triggered by quite innocent events, such as mere rubbing or exposure to cold.

Generalised ordinary urticaria

Generalized ordinary urticaria (hives) presents with spontaneous weals anywhere on the body. It is often classified according to how long it has been present.

  • Acute urticaria is of recent onset (hours, days or a few weeks).
  • Episodic urticaria describes intermittent attacks of urticaria, which may last a few days or a few weeks.
  • Chronic urticaria has persisted for several months or years.

Urticaria may not be present all the time. Some find it more noticeable at certain times of day, or when they are warm or emotionally upset.

Acute urticaria is sometimes due to allergy. Allergy depends on previous exposure to the material, and the development of an immune reaction to it. An immunoglobulin called IgE is involved, which attaches itself to a receptor on the mast cell and causes it to release its chemical mediators.

The cause of an allergy may be:

  • Medicine: most often an antibiotic, but many other drugs have been reported.
  • Food: tiny amounts of fish, eggs, nuts and kiwifruit (many others have been reported less often).
  • Bee or wasp stings.
  • While most allergies involve ingestion,injection or inhalation of the allergen, sometimes allergic urticaria can result from skin or mucosal contact with an allergen e.g. rubber latex.

Most allergies are mild, but very allergic individuals may develop serious anaphylactic shock within a few minutes of exposure. The most frequent causes are antibiotic injections, bee stings or ingestion of peanuts. Anaphylaxis results in urticaria, a tight chest, wheezing, faintness and collapse. Medical attention must be sought urgently. A subcutaneous adrenaline (epinephrine) injection will usually be given. Those prone to anaphylaxis should carry an emergency supply (e.g. an EpiPen™).

Most cases of urticaria are NOT due to allergy. Histamine and other vasoactive chemicals can be released into the skin for many reasons. In these cases urticaria can occur the first time that a person is exposed to the material.

Non-allergic causes of acute urticaria include:

  • Infection, including sinusitis, helicobacter (a cause of stomach ulcers), dental abscess, viral hepatitis, infectious mononuclosis and candida (thrush).
  • Serum sickness, due to blood transfusion, viral infection or medicines (e.g. Ceclor™); urticaria is accompanied by fever, swollen lymph glands, painful joints and nausea. It is thought to result from immune complexes of the allergen and antibodies lodging in small blood vessels.
  • Non-allergic release of mast-cell granules by medicines, especially morphine, codeine, other opiates, and radiocontrast agents. Urticaria provoked by aspirin and other non-steroidal anti-inflammatory drugs involves leukotriene formation.
  • Non-allergic food reactions, from salicylates in fruit, azo dye food colouring agents, benzoate preservatives and other food additives, or from histamine due to bacterial decomposition e.g. scombroid fish poisoning.

Chronic urticaria is often due to autoimmune disease (allergy to one's self), and may be associated with other autoimmune conditions such as thyroid disease and coeliac disease. Circulating ‘anti-idiotypic’ antibodies activate IgE bound on mast cells to cause excessive release of chemicals. More commonly there is no evidence for autoantibodies, and the patient is said to have chronic idiopathic urticaria.

Recurrent angioedema without urticaria may be due to C1 esterase deficiency (the protein C1 INH is missing or abnormal); there is often a family history of similar problems. It may also be caused by angiotensin converting enzyme (ACE) inhibitors such as captopril, quinapril, enalapril and others, which are used to treat heart failure and hypertension. These drugs inhibit kinin breakdown. Angioedema may also be idiopathic (of unknown cause).

Urticaria should be distinguished from urticarial vasculitis, in which weals persist for longer than 24 hours and vasculitis is found on skin biopsy. It results from immune complex deposition.

What Causes Hives and Angioedema?

Hives and angioedema form when, in response to histamine, blood plasma leaks out of small blood vessels in the skin. Histamine is a chemical released from specialized cells along the skin's blood vessels.

Allergic reactions, chemicals in foods, insect stings, sunlight exposure, or medicines can all cause histamine release. Sometimes it's impossible to find out exactly why hives have formed.

There are several different types of hives and angioedema, including:

  • Acute urticaria and/or angiodema: Hives or swelling lasting less than six weeks. The most common causes are foods, medicines, latex, or infections. Insect bites and internal disease may also be responsible.
    The most common foods that cause hives are nuts, chocolate, fish, tomatoes, eggs, fresh berries, soy, wheat and milk. Fresh foods cause hives more often than cooked foods. Certain food additives and preservatives may also be to blame.
    Medicines that can cause hives and angioedema include aspirin and other nonsteroidal anti-inflammatory medications such as ibuprofen, high blood pressure medications (ACE inhibitors), or painkillers such as codeine.
  • Chronic urticaria and/or angioedema: Hives or swelling lasting more than six weeks. The cause of this type of hives is usually more difficult to identify than those causing acute urticaria and/or angioedema. The causes can be similar to those of acute urticaria but can also include autoimmunity, chronic infections, hormonal disorders, and malignancy.
  • Physical urticaria: Hives caused by direct physical stimulation of the skin -- for example, cold, heat, sun exposure, vibration, pressure, sweating, and exercise. The hives usually occur right where the skin was stimulated and rarely appear anywhere else. Most of the hives appear within one hour after exposure.
  • Dermatographism: Hives that form after firmly stroking or scratching the skin. These hives can also occur along with other forms of urticaria.
  • Hereditary angioedema: This is painful swelling of tissue. It is passed on through families.

 

 

 

 

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