Dermographic urticaria

Kobner phenomenon (psoriasis) from friction Dermographic urticaria, pressure urticaria, vibratory angioedema... 

Sheering forces Dermographic urticaria 2-5 min 1-3 Firm stroking with a dermographometer... 

Fig. 1. Lesions of dermographic urticaria, with redness and itching appearing 1 min after application of linear pressure with a dermographometer (picture from Henz et al. (1997))...

Cholinergic dermographic urticaria/cholinergic urticarial dermographism 5-10 20-30 +/-... 

Dermographic urticaria localized erythema and whealing extending over the area of stroking, within seconds to minutes, with associated itching (Fig. 1)... 

Delayed dermographic urticaria development of deep, linear, persisting whealing with mild or no erythema and burning or pain, within 1-4 h after... 

Cholinergic dermographic urticaria appearance of localized erythema and multiple pin-point size wheals and itching, within 5-10 min after stroking... 

Dermographic urticaria and urticarial dermographism as well as delayed urticarial dermographism must be differentiated from delayed pressure urticaria, which is elicited by resting rather than sheering forces. 

Various other types of urticaria have been observed in 25-94% of patients with pressure urticaria. More than 50% have an associated delayed dermographic urticaria (Dover et al. 1988). There is also a slightly increased frequency of atopic diseases in the patient or family history. The increased incidence of positive prick tests is however mostly due to false-positive reactions caused by associated urticarial dermographism (Czarnetzki et al. 1987). An increased incidence of aspirin intolerance is found by some investigators (Dover et al. 1988). 

Localized cold contact urticaria Immediate cold urticaria Delayed cold urticaria Cold-dependent dermographic urticaria Localized cold urticaria Localized reflex cold urticaria Perifollicular cold urticaria Familial delayed cold urticaria Generalized cold urticaria Cold wind and air urticaria Cholinergic cold urticaria... 

Lesions of delayed cold urticaria (Table 4) appear after a latency of 3 h to maximally 24 h after cold exposure and can persist over many hours. In cold induced dermographic urticaria, small wheals appear in skin exposed to the cold only after additional mechanical irritation such as scratching or rubbing. Localized cold urticaria can only be elicited in certain skin areas. In cold reflex urticaria, small transient, but also larger wheals develop only in the vicinity of the area of contact. Follicular cold urticaria is a rare, recently described subtype of cold urticaria, with wheals appearing at sites of cold contact in a perifollicular distribution. In autosomal-dominant delayed familial cold urticaria, deep red swellings appear only after 9-18 h at sites of contact, without previous early reactions. 

Dermographic urticaria is the most frequent form of physical urticaria, and it is characterised by the development of wheals in those sites exposed to even mild traumas (scratching, rubbing, etc.). Moreover, a typical dermographic reaction is present in the case of mastocytosis, even in the absence of apparent skin lesions. 

In some individuals, urticarial weals are provoked by physical stimuli, e.g. friction (dermographism), heat or cold. Exercise may induce weals, particularly on the upper trunk (cholinergic urticaria). Physical urticarias may require combined Hj- and receptor receptor antagonists fully to block the vascular effects of histamine, which causes flushing and hypotension. Cyproheptadine is usually the preferred choice of Hj-antihistamine but causes drowsiness. 

Pressure-induced urticaria and widespread severe dermographism developed after the first apphcation to the scalp of a 0.003% solution of diphencjrprone in a 19-year-old Japanese man (1). Diphencyprone was withdrawn, but the symptoms persisted for almost 3 months. 

Wallengren, J., Moller, H., and Ekman, R. (1987). Occurrence of substance P, vasoactive intestinal peptide, and calcitonin gene-related peptide in dermographism and cold urticaria. Arch. Dermatol. Forsch. 279, 512-515. 

Dexchlorpheniramine competitively antagonizes histamine Hi at receptor sites. It is indicated in treatment of perennial and seasonal allergic rhinitis vasomotor rhinitis allergic conjunctivitis mild, uncomplicated allergic skin manifestations of urticaria and angioedema amelioration of allergic reactions to blood or plasma dermographism and adjunctive anaphylactic therapy. 

It is frequently employed in the treatment of perennial and seasonal allergic rhinitis, allergic conjunctivitis due to inhalant allergens andfoods, simple allergic skim manifestations of urticaria and angioedema, dermographism and anaphylactic reactions as an adjunct to adrenaline. 

The differential diagnosis includes other types of urticaria, particularly dermographic and aquagenic urticaria. The disease should also be distinguished from abortive forms of cold urticaria such as pruritus or prurigo hiemalis (cold itch), cold erythema, cold pruritus and cold panniculitis (Henz et al. 1997). 

There is an increased incidence of atopy (42%). An association with urticarial dermographism, cold urticaria, solar urticaria and aspirin intolerance has been reported for one patient each (Tennenbaum and Lowney 1973 Wise et al. 1978 Willis and Epstein 1974, unpublished own patient). 

Wise RD, Malkinson FD, Luskin A, Gewurs AT, Zeitz HJ (1978) Localized heat urticaria. Arch Dermatol 114 1079-1080 Wong RC, Rairley JA, Ellis CN (1984) Dermographism a review. J Am Acad Dermatol 11 643-652... 

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