Urticaria Kiran V Godse
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FM1URTICARIAFM2
FM3URTICARIA
Editor Kiran V Godse MD DVD FAADV FRCP (Glasg.) Professor Department of Dermatology DY Patil School of Medicine Navi Mumbai, Maharashtra, India
FM4
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Urticaria
First Edition: 2016
9789351529057
Printed at
FM5Contributors
  • Aayushi Mehta
  • Resident
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Aayushi Bagadia
  • Resident
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Aditya Mahajan
  • Resident
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Anoosha P
  • Resident
  • Manipal Hospital
  • Bengaluru, Karnataka, India
  • Clive EH Grattan
  • Consultant Dermatologist
  • St John's Institute of Dermatology
  • London, and Norfolk and Norwich University Hospital
  • Norwich, UK
  • Diana S Church
  • Allergologist, UK
  • Georgios Doumoulakis
  • Department of Allergology
  • Allergie-Centrum-Charite
  • Charite Universitatsmedizin Berlin
  • Chariteplatz 1
  • Berlin, Germany
  • Kiran V Godse
  • Professor
  • Department of Dermatology
  • DY Patil School of Medicine
  • Navi Mumbai, Maharashtra, India
  • Krupa Shankar DS
  • Professor
  • Manipal Hospital
  • Bengaluru, Karnataka, India
  • Manjyot Gautam
  • Associate Professor
  • Department of Dermatology
  • DY Patil School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Marcus Maurer
  • Professor
  • Department of Dermatology and Allergy
  • Allergie-Centrum-Charite
  • Charite Universitatsmedizin Berlin
  • Chariteplatz 1
  • Berlin, Germany
  • Martin K Church
  • Professor
  • Department of Dermatology and Allergy
  • Charite-Universitatsmedizin Berlin
  • Chariteplatz 1
  • Berlin, Germany
  • Mukesh Girdhar
  • Consultant Dermatologist
  • New Delhi, IndiaFM6
  • Murlidhar Rajagopalan
  • Senior Consultant Dermatologist
  • Apollo Hospitals
  • Chennai, Tamil Nadu, India
  • Nicole Schoepke
  • Department of Allergology
  • Allergie-Centrum-Charite
  • Charite Universitatsmedizin Berlin
  • Chariteplatz 1
  • Berlin, Germany
  • Nitin Nadkarni
  • Professor
  • Department of Dermatology
  • DY Patil School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Parag Chaudhari
  • Assistant Professor
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Prachi Bhattar
  • Senior Resident
  • Department of Dermatology
  • DY Patil School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Rajat Kandhari
  • Consultant Dermatologist
  • New Delhi, India
  • Sapna Raj Varma
  • Resident
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Sandipan Dhar
  • Associate Professor and Head
  • Department of Pediatric Dermatology
  • Institute of Child Health Kolkata, West Bengal, India
  • Sanjay Ghosh
  • Medical Director (Honorary)
  • Institute of Allergic and Immonologic Skin Diseases (IAISD)
  • Kolkata, West Bengal, India and Associate Professor,
  • MGM Medical College and LSK Hospital Kishanganj, Bihar, India
  • Sanjiv Kandhari
  • Consultant Dermatologist
  • New Delhi, India
  • Shweta Agarwal
  • Assistant Professor
  • Department of Dermatology
  • DY Patil University School of Medicine
  • Nerul, Navi Mumbai, Maharashtra, India
  • Swati Mogra
  • Resident
  • Department of Dermatology
  • Manipal Hospital
  • Bengaluru, Karnataka, India
  • Torsten Zuberbier
  • Professor
  • Allergie-Centrum-Charite
  • Klinik fur Dermatologie
  • Venerologie and Allergologie
  • Charite-Universitatsmedizin Berlin
  • Chariteplatz 1, Berlin, Germany
  • Vijay Zawar
  • Consultant Dermatologist
  • Shreeram Sankul, Opp. Hotel Panchvati,
  • Vakilwadi, Nashik, Maharashtra, India
FM7Preface
It gives me great pleasure to present this book Urticaria. The Special Interest Group (SIG) on Urticaria was formed in 2009 when Dr Hema Jerajani was the President of the Indian Association of Dermatologists, Venereologists and Leprologists (IADVL). In the last two years, SIG on Urticaria has published patient education pamphlets on this condition and also a consensus statement on the management of urticaria.
The idea of writing this book was given to me by my SIG colleagues and friends who opined that although there were many excellent monographs on this subject, very few books dealt with urticaria from the Indian perspective. In India, though there is no dearth of clinical material, expensive and extensive investigations are often not possible due to financial and logistic constraints.
Our understanding of urticaria has radically changed in the past two decades. For example, today, most cases of chronic urticaria are now accepted to have an autoimmune etiology, and immunomodulating drugs are increasingly being used in the treatment of this condition, frustrating to patient and clinician alike.
Biologics, also known as biologic therapies or biological response modifiers, are drugs derived from living material (human, animal, or microorganism) like omalizumab. These have now been approved for treatment of chronic urticaria.
This book is meant to be companion of busy practicing dermatologists, residents and family physicians.
We are fortunate to have renowned international contributors who have authored four chapters in this book.
We have added four new chapters to this edition of book.
I would appreciate feedback from readers about the contents and presentation so that improvement can be made in future editions.
I wish to thank UCB Pharma for wholeheartedly supporting this venture. Finally, I wish to thank my wife Dr Meenal and children Gauri and Atharva for supporting my academic pursuits at the cost of family life.
I would be remiss if I did not acknowledge my teachers Dr Leslie Marquis, Dr Satish Wadhwa, Dr Srilata Trasi, and Dr Uday Khopkar who have made me what I am today in dermatology. Their debt cannot be lightly forgotten.
Last but not least, I wish to thank Dr Vijay Patil, President of DY Patil Group and Dean and staff of DY Patil Hospital for constant encouragement for my academic pursuits.
Kiran V GodseFM8FM9FM10
FM11Chapters’ Highlights
Urticaria: Historical Aspects
  • Ayurveda mentions urticaria as sheeta pitta
  • H1 antihistamines were discovered in 1937
  • More than 40 antihistamines are available today.
Classification of Urticaria
  • Current guidelines classify urticaria according to clinical manifestations
  • Urticaria is mediated by mast cells
  • According to level of mast cell degranulation clinical signs are superficial (urticaria) or deep swellings (angioedema).
Immunology and Etiopathogenesis
  • Urticaria has varied clinical presentations and multiple etiologies
  • Mast cells may be stimulated by immunologic or nonimmunologic ways
  • Mast cells may be stimulated by activation of high affinity IgE receptors (Fc∑RI) or anti-IgE
  • Biopsy is important to diagnose urticarial vasculitis
  • Autoimmune urticaria can not be diagnosed clinically
  • Histamine is important mediator for itch weal and flare.
Diagnosis of Urticaria
  • Acute urticaria does not need extensive diagnostic procedures
  • Urticaria activity score is useful tool for evaluation
  • CBC, ESR and CRP are important investigations for diagnosis of infections in urticaria
  • Autologous serum skin test is a simple office procedure for diagnosis of autoreactive urticaria.
  • Closed ballpoint pen tip is simple test to diagnose dermographism.
Acute Urticaria
  • Acute urticaria is common disease with hives and angioedema
  • This is short lived disease
  • Viral infections and NSAID are common causes.
Contact Urticaria
  • Appearance of wheals after direct contact with substance is contact urticaria
  • It can be classified as nonimmunologic or immunologic type
  • Common tests to diagnose contact urticaria are open test, prick test and scratch test
  • Treatment is mostly preventive.
Physical Urticaria
  • Symptomatic dermographism is most common type of dermographism
  • There is no allergy involved in symptomatic dermographism
  • Delayed reponse to stimulus is hallmark of delayed pressure urticaria
  • No response to treatment in chronic urticaria may have underlying delayed pressure urticaria (DPU).
  • Montelukast, dapsone, colchicines along with antihistamines are treatment options for DPU.
Angioedema
  • Angioedema without wheals and with wheals have different approach to investigations and management
  • Mast cell dependent angioedema is caused by type I allergy, functional autoantibodies or pseudoallergyFM12
  • Mast cell independent angioedema present without wheals and has bradykinin as primary mediator. Response is poor to antihistamines, epinephrine and steroids
  • Reduced C1 esterase inhibitor function may be hereditary or acquired.
Urticaria and Papular Urticaria in Pediatric Age Group
  • Acute urticaria is more common than chronic urticaria in children
  • Treatment is same as adult urticaria
  • Papular urticaria is due to foreign protein injection by biting insects is common in India
  • Disease improves with age
  • Antihistamines and topical steroid is preferred treatment.
Mastocytosis
  • Cutaneous mastocytosis is commonest form of mastocytosis
  • Darier's sign is pathognomonic of cutaneous mastocytosis
  • Increased number of mast cells in histopathology is diagnostic
  • Long term antihistamines is mainstay of therapy.
Urticarial Vasculitis
  • Urticarial papules and plaques lasting for more than 24 hours is hallmark of urticarial vasculitis
  • Skin biopsy shows features of leukocytoclastic vasculitis or fibrinoid necrosis
  • Immune complex deposition is a cause of UV
  • Course cannot be predicted in UV.
Chronic Urticaria
  • Chronic urticaria has varied presentations and variety of causes
  • Most common causes are autoimmunity, infections and intolerance
  • Nonsedating antihistamines is first-line of therapy.
Antihistamines
  • Histamine receptors should be viewed as cellular switch, which are in off or inactive or on state
  • H1 antihistamines are inverse agonists and not receptor antagonists
  • Efficacy of antihistamine is determined by affinity of drug and concentration of drug at the site of H1 receptors
  • First-generation antihistamines should be discouraged in clinical practice.
Treatment of Chronic Urticaria
  • Main goal of treatment should be identification of underlying cause and treatment for symptomatic relief
  • Updosing of less sedating antihistamines should be tried before using second-line of treatment
  • Autoserum therapy and omalizumab are exciting newer treatment options for resistant urticaria.