Urticarial Reactions

Calcipotriol is a vitamin D3 derivative which is used as a topical agent in the treatment of psoriasis. Although not completely elucidated its mechanism of action seems to be based on inhibition of the proliferation and stimulation of the differentiation of epidermal keratinocytes. Adverse effects include irritation of the skin but also urticarial reactions. Calcipotriol has 100 fold less vitamin D activity as its active vitamin D3 metabolite calcitriol. However, calcipotriol in overdose can cause symptoms of hypercalcemia. 

Sinus problems, hay fever, bronchial asthma, hives, eczema, contact dermatitis, food allergies, and reactions to drugs are all allergic reactions associated with the release of histamine and other autocoids, such as serotonin, leukotrienes, and prostaglandins. Histamine release is frequently associated with various inflammatory states and may be increased in urticarial reactions, mastocytosis, and basophilia. Histamine also acts as a neurotransmitter in the central nervous system (CNS). Upon release from its storage sites, histamine exerts effects ranging from mild irritation and itching to anaphylactic shock and eventual death. 

Mectianism of Action A diagnostic agent that invokes immunoglobulin E which produces type I accelerated urticarial reactions to penicillins. Therapeutic Effect A positive reaction will suggest penicillin sensitivity. 

A 6-year-old boy developed recurrent generalized urticaria 1 year after he started to use human Mixtard insulin (132). The rash started 10 minutes after injections in the arms, thighs, and buttocks, at sites where earlier injections had been given, and disappeared within 12 hours. When he was changed to insulin lispro he had three urticarial reactions in the first 2 weeks and then sporadically. The reactions were treated with chlorphenamine for 2 years. 

A 43-year-old man with type 1 diabetes developed local pruritus, redness, and swelling 4—5 times a week, 15-20 minutes after an injection, subsiding within 1-2 hours (163). Later he had a generalized urticarial reaction 5 minutes after an injection. Insulin lispro did not help. When checked for allergens, he was positive for all types of insulin and negative for additives. With oral mizolastine the local reactions abated for a week, but then reappeared with every injection. Generalized urticaria recurred later. With continuous subcutaneous insulin infusion... 

Non-phenothiazines, such as haloperidol and loxitane, cause fewer urticarial reactions. As with any other class of drug, patients may be allergic to excipients in various tablet or capsule forms, or to preservatives, for example methylparabens in liquid dosage forms (522). 

A 36-year-old woman noted intense exacerbation of urticarial wheals and facial edema 3-4 hours after taking cetirizine 10 mg (21). Skin tests with cetirizine produced an urticarial reaction 5 hours after challenge. Placebo-controlled oral challenge resulted in generalized urticaria, edema of the hands, and intense pruritus 90 minutes after administration of cetirizine, with symptoms lasting up to 12 hours. Skin biopsies showed inflammation typical of urticaria. 

Karamfilov T, Wilmer A, Hipler UC, Wollina U. Cetirizine-induced urticarial reaction. Br J Dermatol 1999 140(5) 979-80. 

Alam M, Gross EA, Savin RC. Severe urticarial reaction to diphenylcyclopropenone therapy for alopecia areata. J Am Acad Dermatol 1999 40(1) 110-12. 

A 30-year-old woman developed a generalized urticarial reaction immediately after the intravenous administration of aminophylline (4). Skin intradermal testing was positive to ethylenediamine. Rechallenge was positive with intravenous aminophylline but negative with diprophylline, which does not contain ethylenediamine. 

The authors identified five previous reports of eiythro-mycin-associated urticarial reactions. However, it was not possible to exclude a reaction to the ingredients of the coated pellets. 

Solar urticaria has been attributed to repirinast in a 72-year-old woman who had taken it for 20 months (2). She developed urticaria immediately after irradiation with 1.5 J/cm of UVA, and a provocation test confirmed that repirinast was responsible for the urticarial reaction, with a spectrum of 320-350 nm. 

Other adverse effects include anaphylaxis " and urticarial reactions, although a controlled study has shown that the incidence of urticaria in patients given benzoic acid is no greater than that with a lactose placebo. ... 

Acute and chronic viral hepatitis are associated with a myriad of extrahep-atic tissue injuries, not all of which are directly related to the cytotoxic effects of HBV and HCV [35, 36], These include skin rashes and urticarial reactions in about 5% of patients with viral hepatitis [37 10], We investigated the possibility that protein Fv purified from patients suffering from HCV infection can activate basophils and mast cells purified from human lung and skin tissues. We found that protein Fv purified from stool extracts of patients with HCV infection induced histamine release from human basophils [32, 41]. Interestingly, the histamine-releasing activity of protein Fv was superimposible with its immunoglobulin-binding property (fig. 2). 

Acute and chronic viral hepatitis infections are associated with many diverse extrahepatic tissue injuries, not all of which are directly related to the cytotoxic effects of HBV and HCV In fact, skin rashes and urticarial reactions occur in about 5% of patients with viral hepatitis [26-28],... 

AntipeniciUin antibodies are detectable in virtually aU patients who have received the drug (and in many who deny previous exposure). Immediate allergic reactions are mediated by skin-sensitizing or IgE antibodies, usually of minor-determinant specificities. Accelerated and late urticarial reactions usually are mediated by major-determinant-specific skin-sensitizing antibodies. Some reactions may be due to toxic antigen-antibody complexes of major-determinant-specific IgM antibodies. 

UNTOWARD EFFECTS Among the hypersensitivity reactions produced by vancomycin are rashes and anaphylaxis. Chills and fever may occur. Rapid intravenous infusion may cause erythematous or urticarial reactions, flushing, tachycardia, and hypotension. The extreme flushing that can occur is called red-neck or red-man syndrome. This results from a direct toxic effect of vancomycin on mast cells to induce histamine release. 

Dermal exposure to toxicants can produce a variety of effects, such as primary irritation, sensitization reactions, phototoxic skin reactions, photoallergy, urticarial reactions, hair loss, chloracne, and cutaneous cancer. These toxic effects and the nature of the reactions are discussed in this section. 

Four patients allergic to liquid polyethylene glycols in topical medications were reported by Fisher (1978). Two had immediate urticarial reactions to PEG 400 and two had delayed allergic eczematous reactions. Cross-reactions occurred between PEG 200,300, and 400. Polyethylene glycols may form formaldehyde by autooxida-... 

Morbilliform exanthema differs markedly in morphological appearance and clinical evolution from the urticarial reaction described above. The skin lesions usually remain stable for a few days (instead of a few hours) and disappear promptly within a few days of interruption of penicillin treatment. It is not rare, however, to observe a mixture of both forms in the same patient. 

Fawcett and Pepys (1976) reported the case of a patient who developed immediate bronchospasm and an urticarial reaction after ingestion of a commercial combination of three tetracyclines no reactions could be elicited by oral challenge with the different tetracyclines, tartrazine, or the blue coating of the drug, whereas a provocation test with the commercial preparation was positive. Other clinical patterns, such as fixed drug eruptions (Kandil 1969 Delaney 1970 Csonka et al. 1971 Brown 1974 Shimizu and Shimao 1977 Pasricha and Shukla 1979), vascular purpura (Schoenfeld 1964) and a picture similar to systemic lupus erythematosus (SLE) (Sulkowski and Haserick 1964) have also been described. Contact dermatitis seems to be a very rare complication it was, however, observed after contact with oxytetracycline (Dohn 1962 Bojs and Moller 1974) and minocycline. In the latter case subsequent oral therapy with the same drug was followed by a systemic reaction and the sensitivity was confirmed by epicutaneous tests (Shelley and Heaton 1973). 

Morphologically, the changes in photoallergic reactions resemble severe sunburn, with edema, papules, red maculae, vesicles, urticarial reactions, and the histological signs of a humorally and/or cell-mediated immunity. 

Hempel M (1975) Klinische Erfahrungen in der lokalen Behandlung von Dermatomykosen mit Econazol-Hautmilch. Mykosen 18 213-219 Hill BHR (1957) An acute urticarial reaction to piperazine citrate. NZ Med J 56 572 Hirsch HA, Dedes M (1974) Local and systemic treatment of vaginal candidiasis. Postgrad Med J [Suppl 1] 50 83-84... 

The results of provocation tests with food additives in chronic urticaria has also been reported by other Danish authors. Brodthagen et al. (1974) found positive reactions in 30% of his patients and Kaaber (1978) found one or more precipitating factors in 35% of 65 patients. When the reactions to various dyes were analyzed in 23 positive patients, 3 reacted to tartrazine and 3 to other azo dyes 5 reacted to annatto, 3 to erythrosine, and 2 to sodium benzoate. From France, Meynadier et al. (1979) recently reported one or more positive reactions in 17 of 24 cases with chronic urticaria. An urticarial reaction was seen after ingestion of aspirin in 10, food colors in 11, and preservatives in 6 patients. 

Citraconic anhydride provokes specific reactions in sensitized guinea pigs (Jacobs Jacobs and coll., 1940) an immediate urticarial reaction after 30 minutes, then a delayed reaction after 6 to 8 hours which subsequently disappears in a few days. The immediate reactions were occasionally accompanied by a generalized rash. 

Ten to thirty minutes after the scratch-test and even after the patch test, an urticarial papule appears. This urticarial lesion appears in a much shorter time if the guinea pig is strongly sensitized. When the immediate urticarial reaction is at its maximum, there is occasionally a generalization of the reaction in the form of papules and there is sometimes even an erythrodermia. This reminds one of the generalized toxicodermal reactions in man (Jacobs, 1940). After about 7 hours, the urticarial lesion at the site of the test undergoes a progressive transformation into a delayed type of reaction, which is well defined, less papular, and less red. Unlike Jacobs (1940), we were unable to determine the moment at which the immediate reaction disappears and the delayed reaction appears. 

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