URTICARIA

&
ANGIOEDEMA

Introduction
As

clinical

various

manifestation
immunologic

of
&

inflammatory mechanism occur

after :

 IgE-or IgE receptor dependent

reaction.
Assc with abnormalities of the
C sys other plasma effector
sys.
Activation

of

cellular

arachidonic acid metabolisme

pathway after mast cell deg.

Epidemiology
1 to 2% have noted, most after
adolescence,

with

highest

incidence in young.
Adult patients with clinical
problem 50% both urticaria &
angioedema.

 Most

common

at

college

students 15 20%.
50% of patients with urticaria
alone

within

year, 20%

continue for 20 years.

 In children, urticaria without

angioedema occur in 80%,
both occur in 15%.
50% for more 1 year, with
mean duration of 16 months.

Classification
Immunologic
IgE-and
IgE
receptor dependent urticaria /
angioedema.
Urticaria
/
angioedema
mediated
by
complement
system & other plasma effector
system.

 Urticaria / angioedema after

direct mast cell degranulator.
Urticaria / angioedema relating
to

abnormalities

of

arachidonic acid metabolism.

Idiopathic
angioedema.

urticaria

The pathogenesis of urticaria

Vasopermeability activities :
Histamine.
Protaglandin D2.
Leukotrine C4.

 Chemotactic factors :
Eosinophil

chemotactic

activities.
Netrophil
activity.

chemotactic

 Enzymes :
Tryptase.
Chymase.
Carboxypeptidase A.
Catepsin G.

 Cytokines :
Tumor necrosis factor .
Interleukin 4,5,6 & 8.
Proteolicans :
Heparin.
Chodroitin.
Sulfate E.
Hyaluron.

Identification of mast
cell products in tissues
or biologic fluids
Skin chamber model mast
cell products appearing.

 Scanning

laser

imaging

mediator

in

Droppler
biochemical

IgE-meadiated

cutaneus reactions.
Intracutaneus

injection

of

specific antigen role IgE & its

interaction with the mast cell.

 HLA-DR4, DRB4 53 & HLADQ8,

DQA

increased
patients.

301

12

frequency

in

Clinical manifestations
Lesions are circumscribed
erythematous, pruritic, edema
that involve the superficial
portion of the dermis are
known as urticaria, when into
the deep dermis it is known as
angioedema.

 Both urticaria & angioedema

may occur in any locations
together.
Angioedema commonly effect
the face / an extremity is
painful or pruritic.

 Lesion

of

urticaria

arise

suddenly, rare persist longer

than 24 48 h and may
continue.
Episodes less than 6 8 weeks
duration are acute, whereas
those

persisting

termed chronic.

longer

are

Immunologic IgE-and IgE

receptor-dependent urticaria
/ angioedema
Atopic diathesis occuring in
individual with personal / family
history of asthma, rhinitis or
eczema IgE dependent.

 Specific antigen sensitivity

foods

(shellfish,

chocolate),

nuts

drugs

&
&

therapeutic agents (penicilin),

helminthic infestation.

 Physical urticaria / angioedema

mechanical

trauma

(elevation in blood histamin

level), prossure (IgE-mediated
has not demonstrated, however
histamine, leukotriene B4, IL6
have been detected).

 Temperature
histamine,
factors,

IgE,

chemotactic
PGD2,

leucotrine

have been documented.

 Light

systemic

lupus

erythematous, 285 320 nm &

400 500 nm, histamine &
chemotactic factors detected
after exposure UVA & UVB, 25
100 kDa.

 Exercise elevation of blood

histamine,
factors,

chemotactic
acetylcholine

receptors increased.

 Stress

IC

nonadrenalin

injection

of

adrenergic

urticaria.
Water blood histamine level
were

elevated

&

mast

cell

degranulation was presented.

Urticaria / angioedema
mediated by the complement
system & other plasma
effector system
Hereditary
&
acquired
angioedema there is a
fungtional deficiency of the
inhibitor of the activated of
C1INH & C3b.

 Necrotizing
venulitis

abnormalities of C1q & IgM

component.
Reactions to the administration
of blood product may arise
after imunization by transfusion
or by plasental tranfer
activated IgG & Hageman factor
fragments.

 Infections hepatitis B virus

infection immune complexmediated necrotizing vasculitis
with cryoglobulinemia.
Angiotensin converting enzyme
inhibitors the mechanism not
to be immunologic because the
lesions occur within hours of
the first dose.

Laboratory findinds
In all patient :
History

&

physical

examination.
Provocative test for physical
urticarias.

 In selected patients :
Complete blood count with
differential analysis.
Erytrocyte

sedimentation

rate.
Urinalysis.
Blood chemistry pofile.

 Stool examination for ova &

parasites.
Antinuclear factor.
Hepatitis B & C virus surface
Ag & Ab.
Skin test for IgE-mediated
reactions.

 Radioallergosorbent

test

(RAST) for specific IgE.

CH50.
Cryoproteins.
Plasma

&

protoporphyris.
Skin biopsy.

erythrocyte

Histopathology
Polymorphous perivascular
infiltrate.
Neutrophils.
Eosinophils.
Mononuclear cells.
Sparse
perivascular
lymphocytes.

Pathology
Chronic idiopathic urticaria
CD4+, CD8+, T lymphocytes,
neu, eusi detected by direct
immunofluorescence, MBP, Pselectin biopsy.
Acut urticaria MBP, ECP.

 Physical urticaria CD4 >

CD8, neu, eosi with MBP, Eselectin, VCAM by histologic
result.
Solar urticaria MBP, ECP.
Papular urticaria T lymp,
macrophages, eosi, neu.

 Chollergic urticaria MBP,

ECP.
Chronic
selectin,

urticaria

E-

P-selectin,

intercellular adhesion mol 1,

VCAM.

Diagnosis &
Differential diagnosis
Urticaria

&

angioedema

episode & evanescent, seldom

persist for > 48 h for several
days.
Several disorder are included in
DD.

 Erythema
edematous,

multiforme

papulovesicular,

bullous eruptions with mucosal

involvement,

typical

iris

or

target.
Lyme borreliosis annuler
edematous, urticarial plaques
may expand in diameter.

 Bullous

pemphigoid

edematous & erythematous

plaques.
Urticaria
generalized

pigmentosa

macular, papular.

red-brown,

Treatment
The ideal treatment for urticaria /
angioedema is identification &
removal of its cause.

 H1-type antihistamine drugs

mainstays.
Newer low-sedating, reduce
sedative, anticholinergic.
If this drug fails to be effective
combination of 2 agent from
different classes may be used.

 Combination of H1 & H2 may be

beneficial & ketotifen has been
used succesfully chronic
urticaria reported (colchine in
combination

with

H1to

benefit) & also cycsporine.

be

Systemic glucocorticoid have no

place in regular therapy.
Prednisone in management of
acute

urticaria

has

been

advocated in emergency rooms.

 Oral disodium cromoglycate is

effective food allergy.
Terbutaline,

-agonist

in

combination with an H1-type

has been reported to be of
benefit idiopathic urticaria
failed

from

conventional

therapy nefidipine.

 Immunoglobulin

(IV)

was

limited benefit & also trials was

of was of benefit with (SC)
interferon- .
Epineprine
particularly

is
in

widely
hospital

used

laryngeal edema, cardivascular

collapse.

 Antihistamine prophylactic
physical urticaria.
17- -alkylated
danazol

androgen
reduction

in

exercise provoked experimental

wheals cholinergic urticaria.

 NSAIDs,

cetrizine,

sulfasalazaline

&

Glucocorticoid

syst.
delayed

pressure urticaria.
Terbutaline

&

aminophylline

combination, H1 & H1 comb.

cold urticaria.

 Propanolol hydrochloride
adrenergic urticaria.
UVA phototherapy & PUVA
photochemotherapy
physical urticaria.

Urticaria / angioedema may be a

source of frustration to both
physician

&

patients,

most

patients can achieve acceptable

symptomatic

control

of

their

disease without identification of

the cause.