Urticaria (or hives) are a kind of skin rash notable for dark red, raised, itchy bumps. Hives are frequently caused by allergic reactions, however there are many non-allergic causes. For example, most cases of hives lasting less than six weeks (acute urticaria) are the result of an allergic trigger. Chronic urticaria (hives lasting longer than six weeks) are rarely due to an allergy. The majority of patients with chronic hives have an unknown (idiopathic) cause. Perhaps as many as 30-40% of patients with chronic idiopathic urticaria will, in fact, have an autoimmune cause. Acute viral infection is another common cause of acute urticaria (viral exanthem). Less common causes of hives include friction, pressure, temperature extremes, exercise, and sunlight. It may be true that hives are more common in those with fair skin.
Weals (raised areas surrounded by a red base) from urticaria can appear anywhere on the surface of the skin. Whether the trigger is allergic or non-allergic, there is a complex release of inflammatory mediators, including histamine from cutaneous mast cells, resulting in fluid leakage from superficial blood vessels. Weals may be pinpoint in size, or several inches in diameter. Angioedema is a related condition (also from allergic and non-allergic causes), though fluid leakage is from much deeper blood vessels. Individual hives that are painful, last >24 hours, or leave a bruise as they heal are more likely to be a more serious condition called urticaria pigmentosa. Hives caused by stroking the skin (often linear in appearance) is due to a benign condition called dermatographism.
Urticaria also called nettle-rash or hives or wheals in a common language, simply means itching with rash. Medically, urticaria may be defined as skin eruption, which is allergic (or non-allergic) in origin and is characterized by profound itching, red circular or irregularly shaped eruptions on any part of the body. Urticaria is an allergic or non-allergic immunological disease, shown on the skin. Characteristically the skin eruptions are erythematous, raised above the skin level, with intense itching and usually worsened by itching an with slight local warmth. It can be acute or chronic; largely having a tendency to recur frequently for many months or years.
These eruptions can remain on the body for variable period, anywhere between few seconds to even hours. They have tendency to disappear and reappear. They tend to disappear without leaving behind any trace.
Location and duration:
Well, urticaria may appear on any part of the skin. Angioedema is a condition when deep tissues are affected. The typical lesions may last for one minute to half an hour. Some may last even longer. Some patients may get the eruptions once in a while and some may have many times during the day. It may be restricted to a couple of spots in some patients, while some may have wide spread rashes appearing for days or even months together.
There are acute, subacute, chronic and recurring variants as far as the frequency and duration are concerned.
Under the microscope, a typical urticarial rash may exhibit perivascular, cellular infiltrate consisting of lymphocytes and eosinophils, is indicative of its allergic behavior. There are findings related to oedema (swelling) and mucosal inflammation.
The Inner War:
The urticaria rash is a symptom of an allergic and immunological event taking place at the dermal level. The exact understanding is illusive to an extent. In brief, urticaria is a hypersensitive reaction due to the histamine release. The histamine release could be from the mast cells when antigens and antibodies (IgM or IgG) combine to activate the immunological reaction. The histamine release could IgE induced. There are certain drugs, pharmacological agents (e.g.: antibiotics, morphine, aspirin, etc.), food articles (proteins, milk products, etc.) Urticaria is a sign of antigen-antibody reaction.
During this process of antibody-antigen reaction, histamine and/or acetyl choline is generated which has the property of causing vessel dilatation (vasodilation) swelling, itching, pain and rash.
The skin lesions of urticarial disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis, and resulting in an edema which persists until the interstitial fluid is absorbed into the surrounding cells.
Urticaria are caused by the release of histamine and other mediators of inflammation (cytokines) from cells in the skin. This process can be the result of an allergic or non-allergic reaction, differing in the eliciting mechanism of histamine release.
Histamine and other pro-inflammatory substances are released from mast cells in the skin and tissues in response to the binding of allergen-bound IgE antibodies to high affinity cell surface receptors. Basophils and other inflammatory cells are also seen to release histamine and other mediators, and are thought to play an important role, especially in chronic urticarial diseases.
In the past decade, it has been noted that many cases of chronic idiopathic urticaria are the result of an autoimmune trigger. For example, roughly one third of patients with chronic urticaria spontaneously develop auto-antibodies directed at the receptor FcεRI located on skin mast cells. Chronic stimulation of this receptor leads to chronic hives. Patients often have other autoimmune conditions such as autoimmune thyroiditis.
Hive-like rashes commonly accompany viral illnesses, such as the common cold. They usually appear 3–5 days after the cold has started, and may even appear a few days after the cold has resolved.
Mechanisms other than allergen-antibody interactions are known to cause histamine release from mast cells. Many drugs, for example morphine, can induce direct histamine release not involving any immunoglobulin molecule. Also, a diverse group of signaling substances called neuropeptides have been found to be involved in emotionally induced urticaria. Dominantly inherited cutaneous and neurocutaneous porphyrias (porphyria cutanea tarda, hereditary coproporphyria, variegate porphyria and erythropoietic protoporphyria) have been associated with solar urticaria. The occurrence of drug-induced solar urticaria may be associated with porphyrias. This may be caused by IgG binding not IgE.
Stress and chronic idiopathic urticaria
Chronic idiopathic urticaria has been anecdotally linked to stress since the 1940s]. There is a large body of evidence demonstrating an association between this condition and both poor emotional well-beingand reduced health related quality of life]. More recent research has investigated hypotheses about stress as a causal factor in triggering the condition. Evidence has been found for a link between stressful life events (e.g. bereavement, divorce etc...)[ and preliminary evidence has been reported for a link between posttraumatic stress and chronic idiopathic urticaria. Less is known about the individual experiences and characteristics of people who develop chronic idiopathic urticaria following stress. Research into these factors in the relationship between stress and chronic idiopathic urticaria is ongoing by a number of researchers, including an online project currently being undertaken by researchers at the University of Plymouth.
The rash that develops from poison ivy, poison oak, and poison sumac contact is commonly mistaken for urticaria. This rash is caused by contact with urushiol and results in a form of contact dermatitis called Urushiol-induced contact dermatitis. Urushiol is spread by contact, but can be washed off with a strong grease/oil dissolving detergent and cool water and rubbing ointments.
• Acute urticaria usually show up a few minutes after contact with the allergen and can last a few hours to several weeks. Food allergic reactions often fit in this category. The most common food allergies in adults are shellfish and nuts. The most common food allergies in children are shellfish, nuts, peanuts, eggs, wheat, and soy. It is uncommon for patients to have more than 2 true food allergies. A less common cause is exposure to certain bacteria, such as streptococcus or possibly Helicobacter pylori. In these cases, the hives may be exacerbated by other factors, such as those listed under Physical Urticarias below.
• Chronic urticaria refers to hives that persists for 6 weeks or more. There are no visual differences between acute and chronic urticaria. Some of the more severe chronic cases have lasted more than 20 years. A survey indicated that chronic urticaria lasted a year or more in more than 50% of sufferers and 20 years or more in 20% of them. Of course this does mean that in almost half the people it clears up within a year and in 80% it clears up within 20 years or less.
• Drug-induced urticaria has been known to result in severe cardiorespiratory failure. The anti-diabetic sulphonylurea glimepiride (trade name Amaryl), in particular, has been documented to induce allergic reactions manifesting as urticaria. Other cases include dextroamphetamine, aspirin, penicillin, clotrimazole, sulfonamides and anticonvulsants.
• Physical urticarias are often categorized into the following.
o Aquagenic: Reaction to water (exceedingly rare)
o Cholinergic: Reaction to body heat, such as when exercising or after a hot shower
o Cold (Chronic cold urticaria): Reaction to cold, such as ice, cold air or water - worse with sudden change in temperature
o Delayed Pressure: Reaction to standing for long periods, bra-straps, elastic bands on undergarments, belts
o Dermatographic: Reaction when skin is scratched (very common)
o Heat: Reaction to hot food or objects (rare)
o Solar: Reaction to direct sunlight (rare, though more common in those with fair skin)
o Vibration: Reaction to vibration (rare)
o Adrenergic: Reaction to adrenaline / noradrenaline (extremely rare)
Angioedema is similar to urticaria, but in angioedema, the swelling occurs in a lower layer of the dermis than it does in urticaria, as well as in the subcutis. This swelling can occur around the mouth, in the throat, in the abdomen, or in other locations. Urticaria and angioedema sometimes occur together in response to an allergen and is a concern in severe cases as angioedema of the throat can be fatal.
Treatment and management
Chronic urticaria can be difficult to treat. There are no guaranteed treatments or means of controlling attacks, and some sub-populations are treatment resistant, with medications spontaneously losing their effectiveness and requiring new medications to control attacks. It can be difficult to determine appropriate medications since some, such as loratadine, require a day or two to build up to effective levels, and since the condition is intermittent and outbreaks typically clear up without any treatment.
Most treatment plans for urticaria involve being aware of one's triggers, but this can be difficult since there are several different forms of urticaria and people often exhibit more than one type. Also, since symptoms are often idiopathic (unknown reason) there might not be any clear trigger. If one's triggers can be identified then outbreaks can often be managed by limiting one's exposure to these situations.
Drug treatment is typically in the form of antihistamines such as diphenhydramine, hydroxyzine, cetirizine and other H1 receptor antagonists. These are taken on a regular basis to protective effect, lessening or halting attacks. While the disease is obviously physiological in origin, psychological treatments such as stress management can sometimes lessen severity and occurrence. Additionally, methods similar to psychological pain management can be used to shift focus away from the discomfort and itchiness during an attack.
The H2-receptor antagonists such as cimetidine and ranitidine may help control symptoms either prophylactically or by lessening symptoms during an attack. When taken in combination with a H1 antagonist it has been shown to have a synergistic effect which is more effective than either treatment alone. The use of ranitidine (or other H2 antagonist) for urticaria is considered an off-label use, since these drugs are primarily used for the treatment of peptic ulcer disease and gastroesophageal reflux disease.