Urticaria & Angioedema

Dr.Andaç Salman
 Key Features

• Transient skin or mucosal swellings due to

plasma leakage
• Superficial dermal swellings: Wheals
• Deep swellings: Angioedema

• Urticaria may present with

wheals/angioedema/both
Wheals

• Pruritic, pink or pale swellings of the superficial dermis

• An initial flare may be present around the lesion
• From a few milimeters to large lesions, few/numerous
• The rule, individual lesions come and go rapidly, usually within 24
hours
• “here today and gone tomorrow”
Angioedema

• Swelling of deeper dermis, subcutis or submucosal tissue

• Mouth, or bowel may also be affected
• Normal or faint pink in color
• Painful rather than itchy
• Larger than wheals
• Lasts longer than wheals, usually 2-3 days
Epidemiology

• Affects 1-5% of the population

• Women>Men
• May present at any age
 Diagnosis-History
Time of Frequency/duration of and Diurnal variation Occurrence in Shape, size, and
onset of provoking factors for wheals relation to distribution of
disease weekends, wheals
holidays, and
foreign travel
Associated Associated subjective symptoms of Previous or current Family and Psychosomatic and
angioedema lesions, for example allergies, infections, personal history psychiatric
itch, pain internal diseases, regarding diseases
or other possible urticaria, atopy
causes
Induction by Use of drugs (e.g., non-steroidal Observed correlation Relationship to Smoking habits
physical anti-inflammatory to food the menstrual (especially use of
agents or drugs (NSAIDs), injections, cycle perfumed tobacco
exercise immunizations, hormones, products or
laxatives, suppositories, ear and eye cannabis)
drops, and alternative remedies)
Hobbies Stress (eustress and distress) Quality of life related Previous therapy Previous diagnostic
to urticaria and and response to procedures/results
emotional impact therapy
Type of work Gastric/intestinal problems Surgical implantations and events during surgery, for
example after local anesthesia
Physical
Examination
Diagnosis-History

• Fever-Arthralgia: Autoinflammatory syndromes?

Urticarial vasculitis?
• Lesions lasting more than 24 hours: Exclusion of
urticarial vasculitis with biopsy
Initial Evaluation

• Is it really urticaria?
• Acute or chronic? “6 weeks”
• Rule out the presence of any kind of physical urticaria
(dermographism etc.)
Classification Urticaria

Acute Urticaria Chronic Urticaria

(<6 weeks) (>6 weeks)

Chronic
Chronic Inducible
Spontaneous
Urticaria
Urticaria

Cold, Delayed Pressure, Heat, Solar,

Dermographism, Cholinergic, Aquagenic
Acute Urticaria

• Less than 6 weeks

• No diagnostic work-up is recommended
• 20-30% becomes chronic urticaria
Chronic Spontaneous Urticaria

• 50% wheals alone, 40% wheals+angioedema

• 10-15% angioedema alone
• In majority of the cases resolves within 1-5 years
Diagnostic Work-up
Diagnostic Work-up
Chronic Inducible Urticaria
COLD URTICARIA
AQUAGENIC URTICARIA
SYMPTOMATIC DERMOGRAPHISM
SYMPTOMATIC DERMOGRAPHISM
DELAYED PRESSURE URTICARIA
CHOLINERGIC URTICARIA
CHOLINERGIC URTICARIA
 Urticarial Vasculitis

Urticarial lesions >24 hours in duration, painful and burning sensation,

residual purpura as they resolve
Extracutaneous manifestations Arthralgias, GI involvement, Renal, Ocular

Associated disorders SLE, Sjögren’s, Serum sickness, HBV, HCV, EBV

infection
Laboratory evaluation CBC, Basic Biochemistry
C3-C4
Disease duation 3 years

Treatment Anthistamines, NSAIDs, Colchicine, Dapsone,

Hydroxychloroquine, MTX
Angioedema

• Angioedema with wheals. Diagnose and treat as urticaria

• Angioedema without wheals

• Drug-induced: ACE inhibitors, ARB, NSAIDs-Normal C4 levels
• Idiopathic: Normal C4 levels
• Hereditary angioedema: Low C4 levels
• Type 1: Decreased levels and function of C1 inh protein
• Type 2: Normal levels but decreased function of C1 inh protein
Treatment

• Avoidance of excessive sweating, stress, alcohol, ASA, NSAID and

ACEinh
• Identification and elimination of any triggering factors
Treatment

• Antihistamines, routine use, not on-demand therapy

• Montelukast
• Colchicine
• Omalizumab
• Ligelizumab…
• Upcoming novel targeted therapies..
Treatment
Treatment
Guidelines