Urticaria Angioedema by mikeholy


									Urticaria & Angioedema

  Richard Honsinger, MACP
      Los Alamos, NM
•   NM Governor , ACP 1991-95
•   Recipient ACP Leadership Award 1999
•   Master, ACP 2000
•   FDA, Pulmonary-Allergy Advisory Comm 2006-2010
•   BOD, American Academy of Allergy, Asthma,
    Immunology 2002-2006

• Clinical Professor, UNM
• Joint Council of Allergy Asthma Allergy &
  Immunology, President-Elect
• Editorial Boards, Annals of AAAI, Proceedings of AAAI,
  Reviewer JACI
• Council of Subspecialty Societies, ACP
                Acute Urticaria
• Antigen exposure
  – Pollen Seasons, Food, Antigen Exposure
• Urticaria with infection
  – Hepatitis, mycoplasma
• Physical Urticaria
  – Dermatographism,Cold,Vibration,Pressure,Solar,Aquagenic
• Cholinergic Urticaria
                 Drug Allergy
•   Medicines (Antibiotics, PPI)
•   Herbal and Natural Medicines
•   Angiotensin Converting Enzyme Inhibitors
•   Radio Contrast Media
•   Not Hormones, Vitamins, non-Proteins
•   Aspirin and NSAID sensitivity
           Physical Urticarias
• May occur so intermittently as to appear
  acute but typically are chronic.
• Physical Urticarias
   – Symptomatic Dermatographism
   – Cold Induced (Familial or Acquired)
   – Vibratory (angioedema)
   – Pressure – induced,
   – Solar
   – Aquagenic
   – Cholinergic
     Angioedema vs Urticaria
• Urticaria – involving the superficial dermis
  – Most often characterized by intense pruritis
    due to histamine effect
• Angioedema – involving deeper dermal
  and subcutaneous layers
  – May be pruritic but often characterized as a
    deeper and dull discomfort – burning quality
• Level of involvement may dictate
  detection and subsequent perception by
   Acute vs Chronic Urticaria
• Acute Urticaria – lasts 6-8 weeks or less
  –   Viral syndromes (especially in young children)
  –   Insect bites or stings (fire ants, scabies)
  –   Food induced reactions (eat this- get that)
  –   Medication related (antibiotics, NSAIDs, narcotics,
       angioedema due to ACE inhibitors)
• Chronic Urticaria – lasting longer than 8
  – Physical urticarias (dermographism, cholinergic,
  – Urticarial vasculitis
  – Urticaria/angioedema associated with
  – Autoimmune urticaria
  – Idiopathic urticaria
Autologous Serum Skin Test
• Serum obtained from patient
   – 0.05 ml injected intradermally
   – Examination of wheal response at 30 minutes
   – Positive test is extension of wheal response by at
     least 1.5 mm greater than original
• Patients with positive skin test associated with
  histamine-releasing FceRI autoantibodies
   – Patients with sera with histamine releasing activity
     had more severe urticaria compared to those without

             Sabroe RA et al. J Allergy Clin Immunol 2002; 110: 494-9
• H-1 antihistamine
   – Sedating (hydroxyzine)
   – Non-sedating (loratadine or fexofenadine)
   – Mildly sedating (cetirizine)
• H-2 antihistamine (ranitidine, famotidine)
• Leukotriene antagonist
   – 5-lipoxygenase inhibitor (zileuton)
   – Leukotriene receptor inhibitor (montelukast, zafirlukast)
• Immune Modulation
                          Rare Disorders
•   Hereditary Angio Edema (HAE)
•   Schnitzler Syndrome (Fever, Hives, Arthralgias)*
•   Muckle Wells Syndrome (Fever, Hives,Deaf,Amyloid)*
•   Melkersson-Rosenthal Syndrome

    * Treated with IL-1 Blockade
          Anakinra, Rilonacept, Canakinumab

Hoffman: J Allergy Clin Immunol 2009;124:1129-1138
• Type I Deficiency of C’1 Esterase Inhibitor
     • Low C’4
     • Low C’1 Esterase Inhibitor (Immunologic Assay)
• Type II Inactive C’1 Esterase Inhibitor
     • Low C’4
     • Inactive C’1 Esterase Inhibtor (Functional Assay)
• Type III Idiopathic and rare.
     • Normal C’4. All females.
     • Factor XII and thrombin abnormality
• Urticaria rarely a serious disease.
• Sequellae rare
• Usually treated with antihistamines
  – Trial of H-2, leukotriene antagonists
  – Avoid corticosteroids.
• Acute Urticaria resolves spontaneously and
  needs minimal therapy and evalutation.
• Chronic Urticaria/Angioedema may need
  immunomodulatory therapy.
• Hereditary Angio Edema is life threatening

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