urticaria and angioedema -...
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Urticaria and Angioedema
Professor W K Jacyk
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Wheal-Urtica
• A central swelling of variable size surrounded by an erythema
• Associated itching
• Fleeting nature, resolves 1-24 hrs
• Swelling upper and mid dermis
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Angioedema
• Swelling of lower dermis and subdermis
• Sometimes pain rather than itching
• Frequent involvement of mucosa
• Lasts longer than urticaria up to 72 hrs
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Classification of urticaria
• Spontaneous- acute , less than 6 months
- chronic, more than 6 mnths
- chronic continuous
- chronic recurrent
Physical urticaria (physically induced)
Contact urticaria
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Physical urticaria
• Dermographic
• Cold
• Heat
• Solar
• Pressure
• Cholinergic
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Aetiology of chronic urticaria 1
• Usually not a single aetiology
• Multifactorial triggers whose importance varies from patient to patient and in 1 patient from time to time
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Aetiology of chronic urticaria 2
• Intolerance of certain foods (additives)
• Aspirin
• NSAIDS
• ACE inhibitors
• Other medications
• Thyroid autoimmunity
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Pathomechanism
• Degranulation of mast cells and release of histamine
• Immunological and non-immunological mechanisms
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Tests of value
• Full blood count and differential counts
• ESR
• Stool for parasites
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Tests of dubious value
• Routine skin tests (RAST)
• IgE levels
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Paramount significance of taking a history
• “if the history gives no inkling of a positive answer to any of the questions, it is highly improbable any investigation will contribute and the patient can be treated symptomatically until the next opportunity to reassess the history”
Champion
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Management 1
• History taking
• Examination of hives
• Avoidance of aspirin and NSAIDS
• Prescribing antihistaminics (anti H1)
• Non-sedative
• Sedative
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Management 2
• Non sedating
loratidine,
Desloratidine
Cetirizine
levo-cetirizine
• Sedating – numerous, several pharmacological groups
i.e. hydroxyzine, cyproheptadine
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Management 3
• Not the first line
• Sytemic corticosteroids
• Cyclosporin
• Methotrexate
• Tricyclic antidepressants
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Erythema multiforme
• Acute, self limiting, frequently recurrent eruption, affecting skin and mucous membranes
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How does it look?
• Eruption of red maculo-papules, often annular
• Often target-like (the centre of the lesion is more oedematous or forms a blister)
• Appears suddenly, often symmetrical
• Sites of predilection-backs of the hands, elbows, knees and face
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Causes
• Most often either caused by HSV or by medications
• Medications – most often
• Phenolphthalein in laxatives, sulphonamides, anticonvulsive
• Other less common causes
Viruses other than Herpes simplex
Bacterial, deep fungal infection
Connective tissue disease
Systemic malignancies
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HSV induced Erythema multiforme
• Has in general a more benign course, affects mainly young adults, involves mucosae less often
• Is frequently notoriously recurrent
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Medication induced erythema multiforme
• Maybe very severe
• Occurs in any age
• Often extensive muco-cutaneous lesions
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Treatment
• Elimination of triggering factors • Acyclovir (other anti herpes agents) prolonged
course • In mild cases Symptomatic, wet dressings, steroid creams • In severe cases Systemic corticosteroids but only in early phase of the
process Act against infection Fluid balance, nutrition Care of eye lesions