Urticaria Hives Disclosures How Common Is It Urticaria Acute by nikeborome

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									                                                      Disclosures
                                                        Employment
                                                        – Harvard Medical Faculty Physicians at
                                                           BIDMC
           Urticaria (Hives)                            Speakers’
                                                        Speakers’ Bureau/Consulting
                  Javed Sheikh, M.D.
                                                           Genentech,
                                                        – Genentech, GlaxoSmithKline,
                                                                         Medpointe,
                                                           Haemonetics, Medpointe, Novartis, Pfizer,
                                                           Sanofi-
                                                           Sanofi-Aventis, UCB
                Clinical Director of Allergy
          Beth Israel Deaconess Medical Center          Research Support
                                                        – GlaxoSmithKline
             Assistant Professor of Medicine
                Harvard Medical School
                                                        Other
                                                        – Haemonetics




        How Common Is It?                               Urticaria: Acute vs. Chronic
• Prevalence (adult and children):                   • Acute
  – 15% to 25% lifetime prevalence                     – Symptoms present for <6 weeks
  – Chronic idiopathic                                 – More common in young
     • Up to 3% of population                          – More common in atopics vs. nonatopics
     • 20% of these have symptoms >10yr




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   Urticaria: Acute vs. Chronic                                                 Urticaria: Clinical Presentation
• Chronic                                                                      • Pink or red bumps with surrounding
  – Symptoms continuously or intermittently (some define                         redness
    this as daily or almost daily) present for ≥ 6 weeks
  – 6 weeks is not an absolute demarcation
                                                                               • Itchy
  – More common in adults                                                      • Each hive usually fades in <24 hours
  – Female:male = 4:1
  – No increased incidence in atopics




          Lesions of Urticaria                                                    Lesions of Chronic Urticaria
                                   Urticaria




                                  Dermographism



                                  Slide Atlas of Clinical Medicine, 1994
                                                                                          Slide Atlas of Allergy, Holgate and Church, 1993




                                                                           2
Lesions of Urticaria                     Angioedema
                           • Swelling of the deeper tissues
                           • May co-exist with urticaria
                             – 50% have both urticaria and angioedema
                             – 40% have urticaria alone
                             – 10% have angioedema alone




                                    Causes: Urticaria &
                                      Angioedema
                           • Allergic reactions
                             – Foods (esp. acute; children)
                                • <2% of chronic urticaria
                             – Food additives/preservatives?
                             – Drugs
                             – Other (e.g. venom, latex)




                       3
         Causes: Urticaria &                        Causes: Urticaria &
           Angioedema                                 Angioedema
• Non-allergic release of histamine       • Infectious
  – Drugs                                   – Viral
     • Aspirin/ibuprofen                    – Parasitic
     • ACE inhibitors                       – Questionable:
     • Narcotics                               • H. pylori, sinusitis, others
  – Certain venoms
  – Contrast dye




         Causes: Urticaria &                        Causes: Urticaria &
           Angioedema                                 Angioedema
• Systemic illnesses/conditions           • Systemic illnesses/conditions (cont)
  – C1 inhibitor deficiency                 – Serum sickness
     • angioedema w/o urticaria             – Rheumatological
  – Complement deficiencies
  – Cryoglobulinemia




                                      4
         Causes: Urticaria &
                                                                    Causes: Urticaria
           Angioedema
• Systemic illnesses/conditions (cont)                 • Physical
  – Thyroid disease                                      – Heat, cold, pressure, vibratory, cholinergic,
  – Certain cancers                                        solar, aquagenic, dermographism, exercise-
  – Other endocrine                                        induced urticaria/anaphylaxis
     • e.g. tumors, ovarian, oral contraceptives




                                                        Cholinergic Urticaria
            Dermographism




                                                                    Slide Atlas of Allergy, Holgate and Church, 1993




                                                   5
            Solar Urticaria                               Solar Urticaria




                                                            Slide Atlas of Allergy, Holgate and Church, 1993




         Causes: Urticaria                      Chronic Idiopathic Urticaria
• Chronic “idiopathic”                        • Autoimmune - in up to 40-60%
                                                – anti-Fc-epsilon-RI
  – 80-90% of all chronic urticaria
                                                – associated with thyroid autoimmunity
  – Excludes all of above causes              • Unknown - the other 40-60%
     • May also have physical urticaria         – limited data regarding food additives, occult
  – No known allergic cause                       infection
                                                – neurogenic component?
  – Up to 40-60% may be autoimmune
                                              • Mast cell or basophil defects




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Management: Urticaria & Angioedema             Management: Urticaria & Angioedema

• Avoidance of known triggers                  • Antihistamines
• Consider food diary if food allergy is         – 1st generation H1 antagonists
  suspected                                      – 2nd generation H1 antagonists
• Consider specialist referral                   – H2 blockers
                                                 – Doxepin




Management: Urticaria & Angioedema                          Management
• Steroids                                     • Epinephrine?
  – Avoid chronic use if possible              • Anti-leukotrienes?




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                Prognosis                               Summary
• Acute                               •   Common, debilitating conditions
• Chronic                             •   Range of possible causes
                                      •   Chronic urticaria is usually “idiopathic”
                                      •   Up to 40-60% of “idiopathic” cases are
                                          autoimmune




                Summary
• 2 main aspects of management:
  – Avoid known triggers
  – Medicines




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