Urticaria and Angioedema

Ailing Zou （邹爱玲） 2021.10.18

Department of Dermatology, Huangshi Central Hospital,
Affiliated Hospital of Hubei Polytechnic College.

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definition

Urticaria

Urticaria is commonly referred to as hives, and

is defined as a localized edema caused by
vasopermeabillity of the skin and mucosa.

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 Etiology and Pathogenesis

 Etiology
Most patients cannot find the exact cause. Common causes include:
• Food, infective, drugs, respiratory tract inhalation, and skin contact.
• Physical factors, mental and endocrine factors, and genetic factors.
• Associated with systemic disease.
 Pathogenesis
Mast cells and other inflammatory cells activate and degranulate, releasing
chemical mediators with inflammatory activity, including metabolites of
the histamine, 5-hydroxytryptophane, cytokine, chemokine, arachidonic
acid (such as prostaglandin and leukotriene), causing vasodilation, vascular
permeability, smooth muscle contraction and glandular secretion

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Clinical Manifestations

Spontaneous urticaria

Induced urticaria

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 Clinical Manifestations

Spontaneous urticaria
 Acute spontaneous urticaria
• Onset of acute, spontaneous wheals and/or angioedema <6
weeks.
• In severe cases, other systems may be involved, resulting in
fever, chest tightness, dyspnea, nausea, vomiting, abdominal
pain, diarrhea, and even allergic shock.
• Most have definite causes, such as infectious, food, drugs.
 Chronic spontaneous urticaria
• Spontaneous wheals and/or angioedema, at least 2 times a week,
for more than 6 weeks.
• Systemic symptoms are mild, but may be acute.
• The cause is indefinite usually.
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 Clinical Manifestations

Induced urticaria
1. Dermatographism
• Linear wheals occur after scratching the skin and usually
accompanied by itching, which can fade after about half an hour.
2. Cold contact urticaria
• It can be divided into familial and acquired.
• After contact with cold air, cold water or cold objects, wheals are
generated at exposed or contacted sites.
• Severe cases may result in chest tightness, palpitation, abdominal
pain, diarrhea, syncope or even shock and laryngeal edema.

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 Clinical Manifestations

Induced urticaria

3. Solar urticaria
• Mainly occurs on skin exposed to sunlight for a few seconds to minutes, after
which the patient experiences the rapid emergence of local itching, redness,
wheals and angioedema. The condition usually lasts from 1 to 2 hours.
4. Delayed pressure urticaria
• After 0.5~24 hours of pressure stimulation, itchy, burning or painful edema
plaques were produced.
• It is commonly found in bearing and persistent compression sites, such as
palm, plantar, hip, ect.

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 Clinical Manifestations

Induced urticaria
5. Hot contact urticaria
• There are two kinds of congenital and acquired.
• The test tube with warm water at 43℃ was placed on the skin. Within a few minutes,
wheals and erythema appeared at the contact site, accompanied by itching or tingling.
6. Vibratory urticaria
• It is divided into primary and acquired types
• Local edema and erythema appear within a few minutes, after the skin is stimulated by
vibration, lasting about 30 minutes.
• These include jogging, rubbing towels back and forth, and even using a seismic machine.

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 Clinical Manifestations

Induced urticaria
7. Cholinergic urticaria
• This usually occurs in adolescence, when the patient undergoes rapid changes in
temperature(normally from cold to hot),or take hot food, or is emotionally unstable.
• The characteristics of the wheals are 1 to 3mm in diameter surrounded by areas of
erythema, with pronounced itching.
8. Contact urticaria
• Wheals and erythemas appear after the skin contacts directly with the allergen.
• It can be caused by food preservatives, additives and other chemicals.

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 Clinical Manifestations

Induced urticaria
9. Aquagenic urticaria
• Wheals appear immediately or several minutes after the skin contacts with water, regardless
of temperature.
• Skin lesions are usually in the upper part of the trunk, with itching, lasting less than 1 hour.
10.Exercise induced urticaria
• Wheals and/or angioedema may occur when eating within minutes or 4 hours after
exercise.
• It can be accompanied by other allergic symptoms, and even shock, associated with certain
specific foods (such as wheat).

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Diagnosis and differential Diagnosis

Diagnosis
Diagnosis is clear based on history and
physical examination, but the analysis of
the causes is usually difficult.

Differential Diagnosis
• Urticaria vasculitis.
• Urticaria papulose.

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Treatment

The principles of therapy is to avoid

the causes and control the symptoms.

Systemic drug therapy

Topical medication

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 Treatment

Systemic drug therapy

1. Acute spontaneous urticaria
• The second generation H1 receptor antagonist is preferred.
• Symptomatic treatment: vitamin C, calcium, spasmolysis medicine, and antibiotics.
• Patients with shock, laryngeal edema and breathing difficulties should be immediately
rescued.
2. Chronic spontaneous urticaria
• Second generation H1 receptor antagonists are preferred, and maintenance therapy is
required after onset.
• Antihistamines may be used in combination or alternately.
• Omazumab and cyclosporine A can be used in the treatment of refractory chronic
spontaneous urticaria.
3. Induced urticaria
Based on the second generation of H1 receptor antagonists, different drugs can be
combined according to different types. 13
Treatment

Topical medicine
 Antipruritus, and calamine lotion can be selected in
summer.
 Antipruritus emulsion can be selected in winter, such as
diphenhydramine cream.
 local block - up agent can be used in solar urticaria.

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definition

Angioedema

Angioedema, also known as "giant urticaria",

is a type of localized edema that occurs in
loose subcutaneous tissue or mucous
membranes. It is divided into acquired and
hereditary. The latter is rare.

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 Etiology and Pathogenesis

 Acquired angioedema
• It often occurs in individuals with allergic diathesis.
• Physical factors such as drugs, food, dust, inhalation, sunlight, cold and
heat are the most common inducements.
 Hereditary angioedema
• Autosomal dominant inheritance, caused by the decrease, lack or
inactivity of C1 esterase inhibitor.
• C1 is abnormally activated and decomposes kinin from C2, which can
increase vascular permeability and cause tissue edema.

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Clinical Manifestations

Acquired angioedema

Hereditary angioedema

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 Clinical Manifestations

Acquired angioedema
 Predisposing parts
• Commonly found in parts with loose skin such as eyelids, lip area and vulva.
• It can also be found on non-loose skin such as extremities of hands and feet.
 Typical rash
• It is mostly a single limited swelling with unclear borders, skin color or pale red,
shiny surface, and elastic touch.
• Itching is not obvious, usually lasts for several hours to several days, and does not
leave traces after subsiding, but it can also occur repeatedly in the same part.
 Involvement of other systems
• Concomitant laryngeal edema can cause breathing difficulties and even death from
suffocation.
• Abdominal pain and diarrhea may occur when the digestive tract is involved.
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Angioedema A: lips; B: foreskin

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 Clinical Manifestations

Hereditary angioedema
 Age of prevalence
• Most patients begin to attack in childhood or adolescence.
• The attacks are often repeated to middle age or even life, but the frequency and
severity of attacks will be reduced after middle age.
 Predisposing parts
• Subcutaneous tissue: often involving the face, hands, upper limbs, lower limbs, and
genitals.
• Abdominal viscera: such as stomach, intestine, bladder, the appearance is similar to
acute abdomen at the onset.
• Upper respiratory tract: disease can cause laryngeal edema.
 Typical skin rash
• The skin lesions are localized, non-pitting subcutaneous edema.
• It is often single, consciously not itching, and it takes 1 to 5 days to subside.
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Diagnosis and differential Diagnosis

Diagnosis
Typical clinical manifestations
Family history
Blood C2, C4 and C1INH levels are
significantly reduced

Differential Diagnosis
• Insect bites

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 Treatment

 Acquired angioedema
• The treatment principle is the same as that of urticaria.
• The second-generation H1 receptor antagonist is preferred.
 Hereditary angioedema
• Treatment is difficult, usually ineffective for glucocorticoid treatment.
• Adrenaline is the only drug that can be temporarily effective during the attack.

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Summary

 Urticaria is a localized edema response due to the expansion of small

blood vessels in the skin and mucous membranes and increased
permeability; clinical features are manifested as wind masses of varying
sizes with pruritus, with or without angioedema; treatment is the second
choice generation H1 receptor antagonist.
 Angioedema is a kind of localized edema that occurs in loose
subcutaneous tissue or mucosa; the treatment principle of acquired
angioedema is the same as that of urticaria.

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THANK YOU
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