Chronic recurrent urticaria: syndrome or disease?

Urticaria is a dermatitis that appears as itchy, swollen red spots on the skin. Allergies are a common cause of hives. Urticaria is characterized by rapid appearance and disappearance within a few hours. But for some people the disease appears again and again.

People prone to hives develop a symptom called angioedema or angioedema. Swelling and puffiness appears on the face - eyelids, lips, as well as ears, arms, legs or genitals. Sometimes angioedema develops into a life-threatening allergic reaction.

Contact your doctor immediately if you notice signs of hives, swelling, or any of the following symptoms:

• Labored breathing;·
• Feeling of squeezing in the throat;
• Nausea and vomiting;
• Cramps or stomach pain;
• Fainting.

Allergies are caused by:

• Medicines, such as antibiotics or aspirin;
• Foods: eggs, nuts, fish or shellfish;
• Something they have touched, such as plants, animal saliva, or latex;
• Insect bites.

If hives are caused by allergies, avoid contact with allergens.

Urticaria is also caused by:

• Infections;
• Cold air, contact with cold water on the skin;
• Changes in body temperature (for example, when you cool down after a hot shower or workout).

If hives last more than six weeks, you most likely do not have an allergy, but the disease is chronic. The causes of chronic urticaria are difficult and rare to identify.

If you are diagnosed with chronic hives, you may need to take medications every day to control the condition. Fortunately, chronic hives disappear over time.

Causes of the disease

Allergic urticaria is one of the types of general pathology: urticaria (urticaria), which, in addition to the allergic mechanism, may have another pathogenesis. The causes of the development of urticaria are divided into exogenous (the influence of external factors) and endogenous (internal).

Exogenous:

• food products – nuts, eggs, fish and seafood, citrus fruits;
• medicines – antibiotics, drugs based on acetylsalicylic acid, non-steroidal anti-inflammatory drugs;
• transfusion of blood and its components;
• chemical – household chemicals, cosmetics;
• physical – cold, high temperature, sun, water;
• insect bites.

Endogenous:

• stress;
• general internal diseases;
• viral infections;
• helminthic infestations.

Often the cause of the development of pathology remains unknown. 90% of cases of the chronic form are of unclear origin.

The causes of allergic urticaria are most often a reaction to food, medications, or an immune response to the effects of toxins released during internal diseases.

How is urticaria treated?

—Hives usually go away within a few days or weeks, even if you are not treated. If you are experiencing hives for the first time, talk to your doctor about whether treatment is needed. If necessary, the first step is to find out what exactly caused the disease. In the future, you need to avoid contact with this substance, the allergen.

To relieve itching, start taking antihistamines. These are the same medications that people take for allergies.

If the hives are generalized or don't go away, your allergist may prescribe medications called steroids. Steroids are effective, but you should not take them for long as they can cause serious side effects. These are not the kind of steroids that some athletes take outside the rules. These steroids only relieve itching and reduce swelling.

Treatment of urticaria in children

It is impossible to predict the body's reaction to a particular allergen, however, every parent can protect their child as much as possible from contact with the most active well-known allergens, do not bundle up or overcool, and do not use cosmetics and detergents with dyes and strong fragrances.
If possible, prevent the presence of children in rooms with a strong smell of paints and varnishes, avoid stress, infections and excessive physical exertion. It is recommended to examine the child’s endocrine system and not ignore signs of weak immunity. Unfortunately, urticaria is often not taken seriously; however, it is a disease that, if unfavorable, can threaten the life of a child.

SM-Doctor pediatricians are always ready to help your child; their experience and attentive attitude to each little patient are the key to a quick and correct diagnosis and well-chosen treatment tactics.

What is chronic urticaria?

-It is characterized by swelling, redness and itching of parts of the skin. Groups of spots remain on the skin for less than a day. Hives appear anywhere on the body. The medical term for urticaria is “urticaria.” "Chronic" means long-term. People with chronic hives experience it most days for six weeks or more. Chronic urticaria is different from urticaria, which occurs suddenly and lasts a short time. This form of the disease can be caused by an allergy or infection. Sometimes sudden hives mean a life-threatening allergic reaction has occurred. You may also experience other symptoms, such as trouble breathing or fainting.

Chronic hives that are not caused by allergies or infections are not life-threatening. But it causes severe itching and interferes with normal sleep. Chronic hives go away over time for most people, but for some it can last for years. There is no cure for chronic hives, but medications can help relieve symptoms.

Publications in the media

Urticaria is a disease manifested by a transient rash, the morphological element of which is a blister (urticaria), i.e. a clearly limited area of ​​edema of the dermis. The color of the blister is red, the diameter is from several millimeters to several centimeters. Statistical data. Urticaria ranks third in the structure of allergic diseases after bronchial asthma and drug allergies. 15–25% of the population will experience urticaria or angioedema at least once during their lifetime.

Etiology • Allergens •• Food, incl. food additives •• Medicinal •• Venom of stinging insects •• Inhalation (pollen, etc.) and contact allergens • Substances that can activate mast cells without the participation of immunological mechanisms •• Acetylsalicylic acid and other NSAIDs •• Iodine-containing radiocontrast substances •• Plasma substitutes (p -ry dextran) •• Local anesthetics •• ACE inhibitors •• Codeine •• Tubocurarine •• Morphine •• Sodium thiopental • Transfusion reactions • Physical factors: heat, cold, insolation, pressure, etc. • Emotional stress • Diseases in which urticaria is one of the syndromes •• Infections - viral (infectious mononucleosis, hepatitis), helminthiases •• Collagenoses (SLE, rheumatoid arthritis) •• Serum sickness •• Cryoglobulinemia •• Mastocytosis •• Neoplastic processes • • Hyper- and hypothyroidism.

Pathogenesis • The appearance of skin elements is associated with the activation of mast cells and their release of mediators (histamine, Pg, leukotrienes), causing a local increase in vascular permeability • Mast cells are activated either through immunological mechanisms (IgE-mediated allergy, complement components - anaphylatoxins C3a and C5a), or directly with certain substances (so-called histamine liberators).

Pathomorphology. Edema and perivascular infiltration of the epidermis and upper dermis by lymphocytes, mast cells, eosinophils, neutrophils with compression of veins and lymphatic vessels.

Classification

• Depending on the stimulus that causes activation of mast cells, immunological and non-immunological forms of urticaria are distinguished •• Immunological urticaria ••• Anaphylactic type, based on an IgE-dependent mechanism caused by the production of reagin antibodies of the IgE class to specific allergens (drugs, food, helminths ) ••• Cytotoxic type - urticaria caused by cytotoxic antibodies occurs as a result of transfusion complications. IgG and IgM antibodies react with isoantigens on the donor's red blood cells, activating the complement system and cytolysis ••• Immunocomplex type. Urticaria appears as a result of the formation of immune complexes that settle on the vascular wall and activate the complement system. Anaphylatoxins and histamine are formed. Causes - administration of vaccines and serums (serum sickness, the clinical manifestation of which is, along with other symptoms, urticaria) •• Non-immunological urticaria ••• Anaphylactoid, associated with the use of histamine liberators (drugs, dextran, benzoates, foods - strawberries, shrimp) or consumption of foods containing histamine and other vasoactive amines (certain types of cheeses, tuna fish, smoked meats, sauerkraut, etc.) ••• Aspirin-dependent ••• Caused by exposure to physical factors (dermographic, temperature - cold, heat, cholinergic, solar, contact, vibration).

• Hereditary forms of urticaria: hereditary angioedema, impaired protoporphyrin metabolism, Schnitzler syndrome (urticaria, amyloidosis, deafness), hereditary cold urticaria, C3 inactivator deficiency.

• Other types of urticaria: idiopathic, pigmentary, infectious, paraneoblastic, endocrine, psychogenic.

• Based on the duration of the disease, acute urticaria (less than 6 weeks) and chronic urticaria (more than 6 weeks) are distinguished.

• In half of patients with chronic urticaria, delayed pressure urticaria is simultaneously observed.

Clinical forms. The nature of the clinical picture of skin lesions is determined by the peculiarity of the vascular network of the dermis (“shock organ”). The main morphological element is a blister, accompanied by itching and characterized by “volatility”, i.e. ability to disappear within a few hours or minutes.

• Acute urticaria •• Often caused by immune mechanisms (food, drug allergens, insect bites) or the action of histamine liberators •• Goes away after a few hours •• May occur in the form of a single episode: characterized by the sudden appearance of blisters and itching, which persist for up to 6 weeks. Individual elements of the rash last no more than 24 hours •• Damage to the respiratory tract and gastrointestinal tract in acute urticaria, in contrast to Quincke's edema, is rarely observed. •• A combination of acute urticaria and Quincke's edema is possible.

• Chronic urticaria •• Persists for >6 weeks •• Caused more often by non-immune mechanisms, incl. systemic diseases •• Often (about 70% of cases) the cause remains unclear.

• Cold urticaria - develops with exposure to cold •• Can be fatal with general cooling (cold urticaria with massive histamine release) •• A common cause is exposure to cold water, cold air. The reaction usually occurs within a few minutes after exposure to cold •• In severe cases, urticaria is accompanied by weakness, headache, dizziness, shortness of breath, and tachycardia. Abdominal pain and nausea may occur •• There is familial cold urticaria - a rare form of urticaria that is inherited in an autosomal dominant pattern •• Reflex cold urticaria - a generalized or local reaction to cold, similar to cholinergic urticaria. Sometimes it occurs only when the whole body cools down. A local reaction to cold is manifested by a rash that appears around the cooled area of ​​the skin, while the skin that was in direct contact with the cold is not affected.

• Cholinergic (thermal) urticaria - small papules (5–10 mm) that occur after overheating, a bath, or a hot shower.

• Physical stress urticaria - provoked by physical activity; manifests itself in the form of cholinergic urticaria, vascular edema, wheezing, and arterial hypotension. Its development is often associated with the intake of allergenic foods.

• Dermographic (mechanical) urticaria - linear papules and redness of the skin as a result of mechanical irritation.

• Solar urticaria is a result of exposure to sunlight. There are several types, depending on the wavelength of light that induces the reactions. Most react to UV rays. Starts in a few minutes; goes away within 1–2 hours after insolation •• There are two types of solar urticaria ••• Type 1 - urticaria mediated by IgE to Ag present only in the blood serum of a patient with urticaria •• Type 2 - urticaria mediated by IgE to Ag present as both in the patient and in a healthy person •• With fixed solar urticaria, the rash appears in the same areas even with irradiation of the whole body.

• Pressure urticaria - occurs 4-6 hours after pressure on the skin (elastic stockings, shoes, etc.). There are two forms of pressure urticaria - immediate and delayed •• Immediate - blisters and erythema appear within a few minutes after pressure is applied to the skin (without rubbing or stretching). The rash is accompanied by a burning sensation and lasts 30 minutes, but no more than 2 hours •• Slow - dark, itchy and painful blisters appear on areas of the body subject to prolonged compression: after long periods of walking or sitting. The rash appears within 30 minutes to 9 hours after skin irritation and persists for about 36 hours. Malaise, chills, and headache are possible.

• Aquagenic urticaria is a rare form. Small papules appear after contact with water at any temperature. In some cases, only itching without urticarial rashes may appear (aquagenic itch). The reaction is associated with mast cell degranulation.

• Contact urticaria - occurs when the skin or mucous membrane comes into contact with certain substances. Characterized by blisters, itching, burning. The most common cause is latex. In severe cases, a complication in the form of anaphylactic shock is possible.

• Idiopathic urticaria - the cause is unclear.

Diagnostics • For reactions to food or drugs - provocative tests with suspected allergens after an elimination diet • Inhalation allergens - skin tests, radioallergosorbent test (RAST) • Idiopathic, lasting more than 6 weeks - exclusion of systemic diseases (skin biopsy, ESR determination, urinalysis , ANAT, etc.) • Provocative tests •• Cold urticaria - cold test: a piece of ice is placed on the skin for 5 minutes; observe the reaction for 10–15 minutes •• Cholinergic or exercise-induced urticaria: exercise test, skin test with methacholine (local reaction to intradermal injection of 0.1 mg in 0.9% sodium chloride solution) •• Solar - insolation of a certain wavelength is carried out •• Delayed as a result of compression: a bag of sand of 2-4 kg is applied for 3 hours •• Aquagenic - tap water of various temperatures is used •• Infectious - bacteriological examination of a smear from the pharynx, titer of antistreptolysins, CRP, analysis stool (for parasites), liver function tests, mononucleosis test •• Autoimmune - ANAT, complement, cryoglobulins, serum protein electrophoresis.

Differential diagnosis • Erythema multiforme • Mastocytosis • Bullous pemphigoid (urticaria stage) • Herpes • Dermatitis herpetiformis.

Treatment • Drugs of choice - antihistamines •• For acute urticaria, first generation drugs are preferable (the effect of second generation drugs mainly manifests itself at a later stage) ••• For adults and children over 6 years old - diphenhydramine 25-50 mg every 6 hours •• • Children under 6 years old - diphenhydramine 5 mg/kg/day •• For chronic urticaria ••• Loratadine 10 mg 1 time / day ••• Cetirizine 0.01 g 1 time / day (evening) or 0.005 g 2 times /day (morning and evening) ••• Cyproheptadine 4–8 mg every 4–8 hours (children - 0.25–0.5 mg/kg/day every 6–8 hours) ••• Fexofenadine-180, once per day ••• Ebastine for adults 10–20 mg 1 time / day, for children in the form of syrup • Alternative drugs •• For chronic urticaria - histamine H2 receptor blockers (cimetidine, ranitidine) in addition to H1 receptor blockers • In severe, resistant in cases of therapy - GC (for example, prednisolone up to 40 mg daily, followed by a gradual dose reduction).

A complication is a severe systemic allergic reaction (bronchospasm, anaphylaxis).

Course and prognosis. Improvement in less than 72 hours in 70% of patients (chronic form - improvement in 30% of patients).

ICD-10 • L50 Urticaria

Notes. The mechanisms of urticaria and Quincke's edema are the same - a localized anaphylactic reaction causes vasodilation, increased vascular permeability of the dermis (urticaria) or subcutaneous tissues (Quincke's edema).

What are the symptoms of chronic urticaria?

People with chronic hives have swollen, red areas on the skin. These areas are often round and pale in the middle. The spots itch, especially at night. Urticaria "capricious lady" - quickly begins and goes away.

Here are some effects on a person that lead to worsening symptoms. These include:

• Overheating in a hot shower or hot, humid weather;
• Tight clothing, tight belts or belts;
• Medicines called non-steroidal anti-inflammatory drugs. This is a group of medications that include aspirin, ibuprofen, and naproxen;
• Alcohol;
• Stress;
• Some spicy foods;
• Cold;
• Insufficient sleep.

Patients with chronic urticaria suffer from angioedema. This process is characterized by massive subcutaneous swelling of the lips, cheeks, eyelids, arms, legs, or genitals (Fig. 2).

Treatment of the disease at the Mama Papa Ya clinic

Clinic "Mama Papa Ya" is located in Lyubertsy. Here we see qualified doctors of various specialties who will provide assistance to patients with urticaria:

• in the clinic you can do the necessary tests and undergo the necessary examination;
• can be treated for both adults and children;
• consultations with specialists in various fields provide the most complete treatment for urticaria;
• We offer affordable prices for medical services and convenient work hours.

To make an appointment, call the phone number listed on the website or through the form provided.

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How is chronic urticaria treated?

Chronic urticaria usually goes away with time. Most patients get better within a year, but the pain lasts for a year or two. To relieve symptoms, doctors prescribe medications. Patients have to take two or three medications daily to control the course of the disease.

Medicines used for chronic urticaria:

• Antihistamines relieve itching and reduce swelling and size of spots;
• Steroid tablets - also help fight itching and swelling.

If these medications do not help, tell your doctor. Over-the-counter creams or lotions rarely help.

How long does hives last?

Typically, the duration of urticaria ranges from a few days to several years. Everything is individual, depending on the type of skin disease. Mild urticaria disappears quickly, usually in young children, when a food allergen hits them. As soon as it is eliminated from food, the rash disappears literally before our eyes. In adults, urticaria occurs in a more acute form with a longer course and manifestation of symptoms. Blisters can last up to a month. This is due to the more complex diagnosis of urticaria. But as soon as the cause is found out and the harmful factor is eliminated, the patient gets better. However, if symptoms appear after one to two months, the urticaria is considered to have become chronic. This type of urticaria can last up to several years. It all depends on the individual characteristics of the human body and lifestyle.

How can I help myself?

Try to avoid taking non-steroidal anti-inflammatory drugs and alcohol. Avoid taking excessively hot showers and wearing tight-fitting clothing. Provide yourself with adequate sleep.

Chronic hives are not caused by food allergies, but some people find that the condition gets worse after eating certain foods. If so, try to avoid these foods. But if the list of such products turns out to be too long, tell your doctor about it.

Forecast and prevention of urticaria

Hives usually go away over time. However, it is impossible to predict how long this problem will persist. In many cases, the disease can be controlled by avoiding trigger substances and taking antihistamines.

Prevention methods include diet control and avoidance of contact with volatile and food allergens. You should wear loose clothing made from natural fabrics and not cause stress in your child. It is unacceptable to neglect chronic diseases.

Before treating hives in a child, you should consult your doctor. Contact a pediatrician or allergist at the RebenOK clinic in Moscow. We employ specialists with extensive practical experience. Thanks to modern equipment, it is possible to quickly diagnose and, based on the results obtained, prescribe effective therapy.

What is inducible urticaria?

-Symptoms of inducible urticaria are red, itchy spots on the skin (Fig. 1). Inducible urticaria forms in response to physical irritation. For example, exposure to excess heat, cold or pressure. Inducible urticaria is known as “physical” urticaria.

The causes of induced urticaria are known:

• Combing
  . As a result of scratching, red, swollen stripes or scratches develop on the skin (Fig. 3). Doctors call this "dermatographism." This type is characterized by the fact that the skin reacts to the action of nails when scratching in areas of itching.
• Cold
  . In people who are sensitive to cold, hives appear after the skin begins to warm up again after cooling.
• Increased body temperature or sweating
  . People who are sensitive to heat or sweat develop many tiny spots when their skin cools after a hot shower or exercise.
• Vibration.
  Signs of hives appear on those parts of the body that touch vibrating objects. Skin irritation occurs on the palms. For example, among motorists when their palm comes into contact with the steering wheel of a car, or among a lawn mower.
• Intense pressure.
  Redness and swelling appear in the part of the body where pressure was applied. For example, after carrying a heavy bag, the palm suddenly swells and swells. Or the soles of your feet swell after a hike.
• Physical exercise.
  Hives that appear during exercise may be a sign of a dangerous problem called anaphylaxis. If symptoms appear after exercise, they are most likely caused by changes in body temperature or sweating.
• Sunlight or water
  . Hives caused by sunlight or water are rare.

Inducible urticaria is considered a chronic type of urticaria.

Diagnostic procedures for urticaria

Diagnosis of acute urticaria is usually quite simple. An examination and questioning of the patient about his medical history is sufficient. Finding out the reason is not so easy, and for this purpose additional research is carried out:

1. Laboratory tests:

• general blood and urine analysis;
• blood biochemistry (liver tests - ALT, AST, bilirubin, rheumatic tests, blood glucose);
• stool examination (coprogram);
• bacterial cultures from the nasal and pharyngeal mucosa.

2. Instrumental research:

• chest x-ray;
• Ultrasound of the abdominal organs;
• endoscopic examinations of the upper and lower gastrointestinal tract (gastroscopy, colonoscopy).

3. Allergy tests:

• intradermal tests with allergens;
• cold and heat tests;
• physical stress tests, line drawing, tourniquet application.

4. Immunological methods.

5. Consultations of related specialists:

• gastroenterologist;
• endocrinologist;
• rheumatologist;
• gynecologist and others as necessary.

First of all, it is important for a specialist to establish what nature the urticaria is – allergic or non-allergic. In the allergic form, one can clearly trace the connection between the symptoms and the introduction of the allergen. It is confirmed by skin, allergy and immunological tests.

Should I see a doctor?

-Consult your doctor if you don't know what causes hives or don't know how to avoid exposure to an allergen.

Some types of induced urticaria are associated with anaphylaxis. For example, if you have cold-induced hives, you may develop anaphylaxis if you swim in very cold water. Another example is exercise-induced anaphylaxis. If you have exercise-responsive hives, it is important to stop and rest immediately if you notice red spots appearing. It is dangerous to continue training.

Symptoms of anaphylaxis are as follows:

• Difficulty breathing, wheezing, whistling sound when breathing.
• swelling of the face, eyelids, ears, mouth, hands, or feet;
• Abdominal cramps, nausea, vomiting, diarrhea;
• Feeling dizzy or faint.

Diagnosis of the disease

First of all, the doctor conducts an anamnesis and examination. In a conversation with the patient, the doctor will clarify the time of appearance of the first rashes, the reasons preceding their occurrence, how long it takes for the blisters to resolve, what else worries the patient, what concomitant pathologies are present, which countries the person has visited recently, whether there have been any insect bites.

During the examination, in addition to the type and location of the rash, the doctor will be interested in the condition of the lymph nodes, the presence or absence of swelling in the joint area, and whether the liver and spleen are enlarged.

To identify the allergen, blood tests (general, biochemical), skin or injection allergy tests are prescribed. Source: Clinical and laboratory features of the course of urticaria. Prokofieva N. B. Dermatovenereology. Cosmetology. Sexopathology, 2011. p. 30-35.

If there is a suspicion that urticaria is caused by physical factors, provocative tests are performed. These are mechanical irritation of the skin, physical activity, hot bath, ice cube test, water compress, photo testing, weight hanging test.

Classification

Modern classifications of urticaria are based on the duration of symptoms of the disease, the reasons for its development and take into account the influence of trigger factors [1, 2]. Thus, acute urticaria is defined as the recurrent appearance of blisters with or without angioedema for no more than 6 weeks. Chronic urticaria recurs for more than 6 weeks. Moreover, in approximately 10–20% of cases, angioedema may be the first and only manifestation of urticaria. About 60% of patients with chronic spontaneous urticaria report episodes of angioedema [3]. In addition to manifestations on the skin, urticaria may be accompanied by pain, swelling of the joints (55.3%), headache/general malaise (47.6%), feeling of heat (42.7%), wheezing or shortness of breath (30.1%), gastrointestinal disorders (26.2%), rapid heartbeat (9.7%) [4].

Urticaria is divided into spontaneous or chronic induced. The group of induced urticaria includes forms of the disease that developed under the influence of physical factors (dermographic, thermal, cold, solar, vibration), as well as non-physical triggers (cholinergic, contact and aquagenic) [2].