Team Leader:

● Labo, Danielle Kaye

Members:
● Arellano, Angelique Dominika
● Dela Cruz, Kiara
● Lee, Kimberlyn Alpha
● Murguia, Diana
● Ventula, Geevee
A CASE DISCUSSION ON

URTICARIA
1
 CASE STUDY
An otherwise healthy 9-year-old Filipino girl presented with a
complaint of generalized, erythematous, pruritic macules and
papules. She had no recent illnesses and normal results of a
school physical examination performed 2 weeks prior to
symptom onset. The patient's medical history showed no
significant information; however, she noted that on multiple
occasions, erythema and pruritic rash appeared on her arms
and face after walking through the freezer aisle of a grocery
store. These rashes subsequently developed on regions where
she scratched and spontaneously resolved 2 to 3 hours later.
She denied having respiratory complaints at that time, and her
symptoms again resolved spontaneously.
 BACKGROUND

● Caused by mast cell activation

in superficial dermis:
● Histamine → pruritus
● Vasodilators → localized swelling

3
 BACKGROUND

1. IgE - mediated (Type 1

Immediate Allergic Reaction)

4
 BACKGROUND

Non-immune Mediated

5
 BACKGROUND

● Also called "hives"

● 1 mm to 10 cm
● Profoundly itchy
● Stimulated by skin contact
● "Come and go"
● May be associated
with angioedema
6
 BACKGROUND

● Acute: short-lived
(usually several days
to a week)
● Chronic: lasting longer
than 6 weeks

7
RISK FACTORS

NON-MODIFIABLE FACTORS:
● Female gender
● Common at third to fifth decade of age
● With history of atopy
● Hereditary diseases

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RISK FACTORS

MODIFIABLE FACTORS:
● Exposure to the following:

9
RISK FACTORS

MODIFIABLE FACTORS:
● Exposure to the following:

10
RISK FACTORS

MODIFIABLE FACTORS:
● Exposure to the following:

11
RISK FACTORS

MODIFIABLE FACTORS:
● Exposure to the following:

12
 CLINICAL MANIFESTATIONS
ONSET

● Acute:
- Develops within minutes to 2 hours after
exposure
- Edematous and erythematous wheal
formation:
Central pallor with surrounding red flare
Single or multiple lesions
Variable size and shape
Typically blanch with pressure
- Pruritus (severe) is common
- Duration <6 weeks

13
 CLINICAL MANIFESTATIONS
Chronic
● Duration > 6 weeks
● 2 or more episodes per week
● Appearance is identical to that of the acute form
● Pruritus sometimes severe
● Many potential triggers
● Idiopathic etiology common

14
 CLINICAL MANIFESTATIONS
Clinical observations

Wheals exhibit:
1 ● Edema
● Erythema
● Well-demarcated edges
● Central pallor
● Surrounding red flare
Wheals dissipate (<24 hours)

2 Pruritus

3 Angioedema
15
 PATHOPHYSIOLOGY
● Urticaria involves dilation
of vascular structures in
the superficial dermis

Initial exposure

Production of an
antigen-specific IgE

IgE binds to mast cell

Subsequent exposure

Mast cell degranulation

16
17
18
 DIAGNOSIS
ACUTE CHRONIC

● Careful history to identify ● Infection

potential triggers ● Autoreactivity
● Physical examination ● Non allergic
● If no causes identified from Hypersensitivity
history, no further investigation
needed due to self limiting
nature with this type of
urticaria

19
 DIAGNOSIS
Laboratory tests:
● More commonly done with chronic urticaria
Usually done to evaluate for the underlying disease
process:
❏ CBC with differential
❏ ESR
❏ CRP
❏ THYROID FUNCTION TESTS
❏ ANAs
❏ ASST

20
 DIFFERENTIAL DIAGNOSIS

● Allergic Contact Dermatitis

● Atopic dermatitis
● Urticarial vasculitis
● Erythema multiforme
● Scabies

21
 DIFFERENTIAL DIAGNOSIS
Clinical URTICARIA(HIVES) ATOPIC
Characteristics DERMATITIS
(ECZEMA)
Manifestation Wheals which are not Dry, rough, pink papules
often filled with fluid

Age group Occurring within the first Most often occurs in

year of child’s life; younger children age 5 or younger
adult: 20-40 y/o

Trigger Trigger when the skin Due to skin inflammation

releases too many
histamine

22
 Difference of Urticaria & Eczema

Hives Eczema

23
 DIFFERENTIAL DIAGNOSIS
Clinical Urticaria Allergic Contact
Characteristics Dermatitis

Reaction Immediate Response Delayed ( takes 24-

72 hrs to manifest)
Duration Transient Stays longer

Body part affected Extracutaneous Skin

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 Difference of Urticaria and Allergic Contact Dermatitis

URTICARIA

CONTACT
DERMATITIS
25
 Clinical Urticaria Urticarial
Characteristics vasculitis

Lesion predilection Anywhere Dependent areas, areas

under focal pressure,
anywhere

Symptoms Intensely pruritic Painful, tender, burning,

pruritic

Persistence Less than 24 hours [usually More than 24 hours

30 minutes–24 hours] [usually 24–72 hours]

Residual signs None Purpura or

hyperpigmentation
26
Difference of Urticaria and Urticarial Vasculitis

27
 Clinical Urticaria Erythema Multiforme
Characteristics
Morphology Annular wheals with central pallor or Erythematous papules,target
ecchymosis lesions, eventually central
Duration of wheal <24hrs necrosis or vesicles
Often angioedema on face and Duration > 7 days
extremities

Location Universal Palms and soles

Symptoms Pruritus Burning, mild pruritus

Triggers Infections, medicines and food Infections, herpes

Treatment Antihistamines Topical steroid

ointments,systemic steroids
with spread lesions

28
Difference of Urticaria and Erythema Multiforme

Urticaria
Erythema Multiforme 29
 Clinical Urticaria Scabies
Characteristics

What it is Allergic reaction Infectious reaction

Causes Due to an immune Because of a living

response mite
Symptoms Small, round red Rashes with intensive
patches on the surface itchiness
of the skin
Treatment Avoid contact and with Maintain health and
doctor prescription hygiene and application
taking antihistamines. of sulfur-based
medicine.
30
Difference of Urticaria and Scabies

31
 OTHER CONDITIONS THAT MAY BE CONFUSED
CONDITION WITH URTICARIA
DISTINGUISHING CHARACTERISTICS

Arthropod bites Lesions last several days,insect exposure history

Fixed drug eruptions Offending drug exposure,not pruritic,hyperpigmentation

Henoch -Schonlein Lower extremity distribution,purpuric lesions,systemic

purpura symptoms

Morbiliform drug reactions Maculopapular rash associated with medication

Pityriasis Rosea Lesions lasts weeks, herald patch, ‘’Christmas tree’’pattern,

often not pruritic
Viral exanthem Not pruritic,prodrome,fever, maculopapular lesions, individual
lesions last for days
32
Arthropod bites

Viral exanthem

Morbiliform drug rxns

33
MANAGEMENT

34
MANAGEMENT

● Treating the underlying

causes:
If the cause can be identified,
eliminate the cause.
● Prevention of and care for
dry skin
● Avoidance of skin
stimulation
35
PHARMACOLOGICAL
MANAGEMENT
(specific to the case)

36
MECHANISM OF ACTION OF ANTIHISTAMINES

37
MECHANISM OF ACTION OF ANTIHISTAMINES

38
MECHANISM OF ACTION OF ANTIHISTAMINES

39
MECHANISM OF ACTION OF ANTIHISTAMINES

40
MECHANISM OF ACTION OF ANTIHISTAMINES

41
MECHANISM OF ACTION OF ANTIHISTAMINES

42

HYDROXYZINE, DIPHENHYDRAMINE
MOA
inverse agonism at H1
receptor
Clinical Application:
Hay fever, angioedema,
motion sickness, used orally
as OTC sleep aid; used
parenterally for dystonias
often used as a sedative,
antiemetic, and anti-motion
sickness drug
H1 Antihistamines (First Generation)
Dosing SIDE EFFECTS
1. >6 years old: 50-100 BOXED WARNING:
Taking higher than recommended doses
mg/day PO divided q6hr of the common over-the-counter (OTC)
allergy medicines can lead to serious
heart problems
2. 6-12 years: 12.5-25 mg PO
q4-6hr; not to exceed 150 SIDE EFFECTS:
mg/day Dry mouth, Drowsiness, Allergic
reaction, Headache, Hallucination
Sedation
ROA: ORAL
DOA: 4-6h MONITORING:
May cause oversedation and confusion
in elderly patients. Start on lower doses
and monitor closely.
43
 H1 Antihistamines (Second Generation)
CETIRIZINE
(Fexofenadine, Levocetirizine, Loratadine & Desloratadine)

MOA Dosing SIDE EFFECTS

MOA: these drugs are competitive
inhibitors at the H1 receptors.
-Second generation agents: these agents
are lipophobic and were developed to
avoid sedation and anticholinergic activity
of the first-generation drugs
1. >6 years: 5-10 mg PO qDay; max: 10 mg SIDE EFFECTS:
qDay Have minimal toxicities
2. 6-12 years: 30 mg PO BID
3. 6-12 years: 2.5 mg PO qDay in evening
4 & 5: > 6 years: 10 mg PO qDay

INDICATION: IgE immediate allergies; ROA: ORAL

especially hay fever, urticaria, DOA:12-24h
angioedema

44
 Drug Dosing Safety/Side effects/Monitoring

H1 Antihistamines MANAGEMENT
(Second
Generation)

1. >6 years: 5-10 mg

1. Cetirizine PO qDay; max: 10 Notes :
2. Fexofenadine mg qDay
● Do not take more than directed
3. Levocetirizine ● Do not take at the same time as
4. Loratadine 2. 6-12 years: 30 mg aluminum or magnesium antacids
5. Desloratadine PO BID ● Do not take with fruit juices
3. 6-12 years: 2.5 mg ● Stop use if allergic reaction to this
PO qDay in evening product occurs; seek medical help right
4 & 5: > 6 years: 10 mg away if symptoms do not improve after 3
days of treatment.
PO qDay

45
First vs. Second generation H1 antihistamines

46
 H2-Receptor Antagonists
CIMETIDINE, RANITIDINE

MOA Dosing SIDE EFFECTS

Dosing: BOXED WARNING:

Competitive should be taken with foods
pharmacologic block of H2 Cimetidine: 300 mg every 6 hrs
receptors. Ranitidine: 150 mg daily
SIDE EFFECTS:
Headache
Used for PEPTIC ULCER ROA: ORAL, PARENTERAL CYP450 inhibitor and antiandrogen
DISEASE, Zollinger-Ellison effects (gynecomastia - cimetidine),
Syndrome,
DOA: 12-14 hrs for large doses
decreased hepatic flow - cimetidine
Gastroesophageal reflux
MONITORING:
Monitor gastric pH, CBC, renal
function (to adjust dose), occult
blood with GI bleeding; prothrombin
time (in concomitant use with
anticoagulants). Assess for signs of
confusion.

47
MOA OF H2RA

48
 PREVENTION
● Patients with acute urticaria should avoid any medication, food, or other allergen
that has precipitated urticaria (hives) or other serious allergic reaction previously.
● Choosing mild or fragrance-free soaps, skin creams, and detergents
● Taking over-the-counter antihistamines when the pollen count is high, if pollen
may be a trigger
● Using meditation and other relaxation techniques to manage stress
● Patients with chronic or recurrent urticaria should be referred to a dermatologist
for further evaluation and management.
● Consultation with or referral to a dermatologist, allergist, immunologist, or
rheumatologist may be appropriate in selected cases, particularly in cases of
complicated, recurrent, refractory, severe, or chronic urticaria. Dermatology
referral is mandatory if urticarial vasculitis is suspected.
49
 REFERENCES
● Basic & Clinical Pharmacology 14th Edition by Bertram G. Katzung, MD, PhD
● Asero R. (2020). New-onset urticaria. In Saini S, Callen J. (Eds.), UpToDate. Retrieved March 14, 2021, from
https://www.uptodate.com/contents/new-onset-urticaria
● Khan D. (2020). Chronic spontaneous urticaria: standard management and patient education. In Saini S, Callen
J. (Eds.), UpToDate. Retrieved October 23, 2022, from
https://www.uptodate.com/contents/chronic-spontaneous-urticaria-standard-management-and-patient-education
● Saini S. (2021). Chronic spontaneous urticaria: clinical manifestations, diagnosis, pathogenesis, and natural
history. In Callen J. (Ed.), UpToDate. Retrieved October 23, 2022, from
https://www.uptodate.com/contents/chronic-spontaneous-urticaria-clinical-manifestations-diagnosis-pathogenesi
s-and-natural-history
● Wong H. (2020). Urticaria. In Elston D. (Ed.), Medscape. Retrieved October 23, 2022, from

https://reference.medscape.com/article/762917-overview
● Lippincott Illustrated Reviews Pharmacology South Asian Edition by Shalma & Velpandian

50
 TEAM MEMBER CONTRIBUTIONS
Clinical Manifestation, Diagnosis
Labo,
Danielle

Management and Prevention

Arellano,
Angelique
Pathophysiology, Pharmacological Dela Cruz,
management Kiara
Pathophysiology, Pharmacological Lee,
management
Kimberlyn
Pathophysiology, Pharmacological Murguia,
management Diana

Background, Risk factor, Case Ventula,

study
Geevee 51
MESSAGE FOR
MEDICAL STUDENTS:

52
THANK YOU!

53
 10 MULTIPLE CHOICE QUESTIONS
1.What is the drug of choice for urticaria?
a. Diphenhydramine B. Loratadine C. Cetirizine D. All of the above

2. How does h1 antihistamines help in the treatment of urticaria?

A. primary mechanism of antihistamine action in the treatment of allergic diseases is believed to be competitive
antagonism of histamine binding to cellular receptors (specifically, the H1-receptors)
B. H1-antihistamines are the cornerstone of symptomatic treatment in acute and chronic urticaria, in which they not
only relieve itching, but also reduce the number, size, and duration of urticarial lesions.
C. BOTH D. NONE OF THE ABOVE

3. What is the difference of 1st generation and 2nd generation antithistamines?

a. 1st generation are older generations and are sedating.
b. First-generation antihistamines block both histaminic and muscarinic receptors as well as passing the blood-brain
barrier. Second-generation antihistamines mainly block histaminic receptors and do not pass the blood-brain
barrier.
c. 2nd generation AH causes sedation also but lesser compared to 1st gen.
d. All of the above

4. Why are h1 antihistamines contraindicated with glaucoma?

e. they have atropine like properties B. They also cause mydriasis C. They stimulate the adrenergic alpha 1
receptors
f. All of the above
54
 10 MULTIPLE CHOICE QUESTIONS
5. Why are these anti-allergy drugs still contraindicated to patients with hypersensitivity when
their main action is to block hypersensitivity to an allergen?
a. Because of their additive ingredients B. Because they fail to deliver their therapeutic dose
c. Because the drug is cheap and a generic one only D. All of the above
6. Why should you not take the drug with fruit juices?
b. Because they can irritate the stomach and cause hyperacidity leading to decreased absorption of the
drug
c. Fruit juices like grapefruit juice is an enzyme inhibitor
d. Bec the taste is not pleasant d. Taking drugs with fruit juices can make you vomit
7. How can glucocorticoids help in the treatment of urticaria?
e. stabilize mast cell membranes and inhibit further histamine release.
f. They reduce the inflammatory effect of histamine and other mediators
g. Both a and b d. None of the above
8. Why is prednisone not recommended for long term use?
h. Bec. it Can make you fat b. Can suppress your immune system c. It can lead to cushings syndrome
d. All of the above
9. why is doxepin contraindicated with MAOIs?
i. It can aggravate the side effects of maois b.It is a competitive inhibitor of maois c. Both
d. NOTA
10. What drug is used in cases of anaphylaxis?
j. Dopamine B. Dobutamine c. noepinephrine d. epinephrine 55