Urticaria and Angioedema

Avoidance measures and oral double-blinded, placebo-controlled food challenges may be necessary to confirm the role of an allergen. Other substances may induce urticaria by non-IgE-mediated mechanisms, like additives, aspirin or 

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This form of urticaria is usually due to an IgE-mediated reaction causing the release of biologically active factors from basophils and mast cells (Table 3). The initial response, occurring within minutes, is erythema caused by dilation of small blood vessels in the dermis. The wheal accompanying the erythema is due to increased capillary permeability causing transudation of fluid. Histamine is the major mediator involved in urticaria. Indeed, intradermal injection of histamine, as positive control for allergen skin prick tests, produces a wheal-and-flare response with pruritus similar to the urticarial lesions. Histamine is produced mainly by mast cells but also by basophils (73). 

Cutaneous mast cells and their mediators play a central role in the pathogenesis of urticaria. In the skin, mast cells are predominantly of the type containing 

Higher prevalence of acute urticaria in atopic patients Presence of allergen-specific IgE in patients with acute urticaria Correlation between allergen exposure and flares of acute urticaria Urticaria induced by cross-linking of EceRl 

It seems clear that all patients with urticaria should avoid taking aspirin in any form (Kaplan 1978). Care should be taken also to exclude from the diet food and drug additives and colorants (e. g., benzoates, or tartrazine) to which some patients are intolerant (Juhlin et al. 1972). Recent surveys report intolerance to tartrazine (a yellow dye widely used with foods, drinks, and drugs) as amounting to 8% (Set-tipane et al. 1976) and 13% (Dry et al. 1979) among patients with chronic urticaria. A simple diet free of aspirin and food and drug additives leads to rapid improvement in a substantial number of patients with chronic urticaria (Rudzki 1977). 

There is a subgroup of patients who can be clearly distinguished from all the others who link their cutaneous reactions to aspirin ingestion. In this subgroup, in- 

Impurities contaminating commercial aspirin preparations could be responsible for appearance of urticaria and angioedema in some patients (de Weck 1971 Bundgaard and de Weck 1975). These contaminants include acetylsalicylic anhydride, acetylsalicylic salicylic acid and cw-disalicylide. A rapid and convenient colorimetric method has been described recently for the quantitative determination of these immunogenic impurities in aspirin (Bundgaard 1976). 

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Brompheniramine VaZol also is indicated for the temporary relief of runny nose and sneezing caused by the common cold treatment of allergic and nonallergic pruritic symptoms temporary relief of mild, uncomplicated urticaria and angioedema amelioration of allergic reactions to blood or plasma adjunctive therapy in anaphylactic reactions. 

Type I IgE-mediated acute allergic reactions to stings, pollens, and drugs, including anaphylaxis, urticaria, and angioedema. IgE is fixed to tissue mast cells and blood basophils, and after interaction with antigen the cells release potent mediators. 

Urticaria and angioedema Allergic contact dermatoconjunctivitis Allergic contact dermatitis Photoallergic contact dermatitis Irritative or toxic contact dermatitis Phototoxic dermatitis Cumulative deposition... 

Urticaria and angioedema e.g. penicillins, ACE inhibitors, gold, NSAIDs, e.g. aspirin, codeine. 

ACE inhibitors cause persistent dry cough in 10-15% of patients. Urticaria and angioedema (< 1... 

Kelkar PS, Butterfield JH, Teaford HG. Urticaria and angioedema from cyclooxygenase-2 inhibitors. J Rheumatol 2001 28(11) 2553. ... 

The clinical picture of hypersensitivity reactions varies from vasomotor rhinitis, urticaria, and angioedema to serious bronchoconstriction and in some cases anaphylactic shock. 

A maximum of 20% of subjects with a history of allergylike reactions after administration of a penicillin antibiotic have positive skin or RAST tests (165-167). Tests using benzylpenicillin derivatives or semisynthetic penicillins can almost double positive test results (168,169). Patients with a positive history but negative skin tests run a 1-3% risk of an IgE-mediated reaction and 60% of testpositive patients had evidence of an immediate reaction, including urticaria and angioedema (165). 

Systemic allergic reactions have been reported in eight patients after topical application of a wart formulation containing resorcinol (3). All developed a marked eczematous, sometimes bullous reaction, localized to the site of application in four cases there were generalized urticaria and angioedema, in one pompholyx eczema, and in three generalized eczema with pompholyx. In aU cases there were positive patch tests with resorcinol. 

A wide range of adverse events has been reported in most patients (5). A transient flu-hke syndrome is very common (50-90%), particularly after the first infusion of rituximab, and is often associated with various hypersen-sitivity-hke symptoms (5-20%). In the most severe cases, patients had hfe-threatening cytokine release syndrome with dyspnea, bronchospasm, hypoxia, hypotension, urticaria, and angioedema. Deaths have been reported in eight of 12 000-14 000 patients after drug launch. 

Sokol WN, Hydick IB. Nasal congestion, urticaria, and angioedema caused by an IgE-mediated reaction to sodium metabisulfite. Ann Allergy 1990 65(3) 233-8. 

The precise mechanisms of many drug reactions are not known, although the reactions are believed to be immune mediated. Perhaps most common are the delayed dermatologic reactions that occur with a variety of drugs (especially penicillins and sulfonamides). These reactions may be evident as macropapular, morbilliform, or erythematous rashes exfoliative dermatitis photosensitivity reactions or eczema. These reactions also may be manifest as pruritus, urticaria, and angioedema. 

Vaida GA, Goldman MA, Bloch KJ Testing for hepatitis B vims in patients with chronic urticaria and angioedema. J Allergy Clin Immunol 1983 72 193-198. 

Clemastine competitively antagonizes histamine at Hj-receptor sites and is indicated in the relief of symptoms associated with allergic rhinitis or other upper respiratory allergies, such as sneezing, rhinorrhea, pruritus, and lacrimation and relief of mild, uncomplicated allergic skin manifestation of urticaria and angioedema. 

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. 

Diphenhydramine is an Hj-antihistaminic agent with anticholinergic and sedative properties. Diphenhydramine (25 to 50 mg t.i.d.) is indicated in allergic conjunctivitis, urticaria, and angioedema resulting from food, blood, or plasma in combination with epinephrine in anaphylactic... 

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