Urticaria Angioedema Alwi

8/20/2019 Urticaria Angioedema Alwi

1/53

URTICARIAURTICARIA

&&

ANGIOEDEMA ANGIOEDEMA


2/53

IntroductionIntroduction

As clinical manifestation ofAs clinical manifestation of

various immunologic &various immunologic &

inflammatory mechanism occurinflammatory mechanism occur

after :after :


3/53

• IgE-or IgE receptor dependentIgE-or IgE receptor dependent

reaction.reaction.• Assc with abnormalities of theAssc with abnormalities of the

C sys other plasma effectorC sys other plasma effectorsys.sys.

• Activation of cellularActivation of cellular

arachidonic acid metabolismearachidonic acid metabolisme

pathway after mast cell deg.pathway after mast cell deg.


4/53

Epidemiology

Epidemiology

• 1 to ! have noted" most after1 to ! have noted" most after

adolescence" with highestadolescence" with highest

incidence in young.incidence in young.

• Adult patients with clinicalAdult patients with clinical

problem #$! both urticaria &problem #$! both urticaria &

angioedema.angioedema.


5/53

• %ost common at college%ost common at college

students 1# $!.students 1# $!.

•

#$! of patients with urticaria#$! of patients with urticaria

alone within 1 year" $!alone within 1 year" $!

continue for $ years.continue for $ years.


6/53

• In children" urticaria withoutIn children" urticaria without

angioedema occur in '$!"angioedema occur in '$!"

both occur in 1#!.both occur in 1#!.

• #$! for more 1 year" with#$! for more 1 year" with

mean duration of 1( months.mean duration of 1( months.


7/53

ClassificationClassification

• Immunologic IgE-and IgEImmunologic IgE-and IgE

receptor dependent urticaria )receptor dependent urticaria )


• *rticaria ) angioedema*rticaria ) angioedema

mediated by complementmediated by complementsystem & other plasma effectorsystem & other plasma effector

system.system.


8/53

• *rticaria ) angioedema after*rticaria ) angioedema after

direct mast cell degranulator.direct mast cell degranulator.

• *rticaria ) angioedema relating*rticaria ) angioedema relating

to abnormalities ofto abnormalities of

arachidonic acid metabolism.arachidonic acid metabolism.

• Idiopathic urticaria )Idiopathic urticaria )



9/53

The pathogenesis of urticaria The pathogenesis of urticaria

• +asopermeability activities :+asopermeability activities :

,istamine.,istamine.

rotaglandin .rotaglandin .

/eu0otrine C./eu0otrine C.


10/53

• Chemotactic factors :Chemotactic factors :

Eosinophil chemotacticEosinophil chemotactic

activities.activities.

2etrophil chemotactic2etrophil chemotactic

activity.activity.


11/53

• En3ymes :En3ymes :

4ryptase.4ryptase.

Chymase.Chymase.

Carbo5ypeptidase A.Carbo5ypeptidase A.

Catepsin 6.Catepsin 6.


12/53

• Cyto0ines :Cyto0ines :

4umor necrosis factor4umor necrosis factor .. Interleu0in "#"( & '.Interleu0in "#"( & '.

•

roteolicans :roteolicans :,eparin.,eparin.

Chodroitin.Chodroitin.

7ulfate E.7ulfate E.

,yaluron.,yaluron.


13/53

• 70in chamber model70in chamber model mastmast

cell products appearing.cell products appearing.

Identification of mastIdentification of mast

cell products in tissuescellproducts in tissuesor biologic fluidsor biologic fluids


14/53

• 7canning laser roppler7canning laser roppler

imagingimaging biochemicalbiochemical

mediator in IgE-meadiatedmediator in IgE-meadiated

cutaneus reactions.cutaneus reactions.

• Intracutaneus in8ection ofIntracutaneus in8ection of

specific antigenspecific antigen role IgE & itsrole IgE & its

interaction with the mast cell.interaction with the mast cell.


15/53

•

,/A-9" 9 #; & ,/A-,/A-9" 9 #; & ,/A-


16/53

Clinical manifestationsClinical manifestations

• /esions are circumscribed/esions are circumscribed

erythematous" pruritic" edemaerythematous" pruritic" edema

that involve the superficialthat involve the superficial

portion of the dermis areportion of the dermis are

0nown as urticaria" when into0nown as urticaria" when intothe deep dermis it is 0nown asthe deep dermis it is 0nown as



17/53

• oth urticaria & angioedemaoth urticaria & angioedema

may occur in any locationsmay occur in any locations

together.together.

• Angioedema commonly effectAngioedema commonly effect

the face ) an e5tremity isthe face ) an e5tremity is

painful or pruritic.painful or pruritic.


18/53

• /esion of urticaria arise/esion of urticaria arise

suddenly" rare persist longersuddenly" rare persist longerthan ' h and maythan ' h and may

continue.continue.• Episodes less than ( ' wee0sEpisodes less than ( ' wee0s

duration are acute" whereasduration are acute" whereas

those persisting longer arethose persisting longer are

termed chronic.termed chronic.


19/53

Immunologic IgE-and IgEImmunologic IgE-and IgE

receptor-dependent urticariareceptor-dependent urticaria/ angioedema/ angioedema

• Atopic diathesisAtopic diathesis occuring inoccuring in

individual with personal ) familyindividual with personal ) family

history of asthma" rhinitis orhistory of asthma" rhinitis or

ec3emaec3ema IgE dependent.IgE dependent.


20/53

• 7pecific antigen sensitivity7pecific antigen sensitivity

foods >shellfish" nuts &foods >shellfish" nuts &

chocolate?" drugs &chocolate?" drugs &

therapeutic agents >penicilin?"therapeutic agents >penicilin?"

helminthic infestation.helminthic infestation.


21/53

• hysical urticaria ) angioedemahysical urticaria ) angioedema

mechanical traumamechanical trauma

>elevation in blood histamin>elevation in blood histamin

level?" prossure >IgE-mediatedlevel?" prossure >IgE-mediated

has not demonstrated" howeverhas not demonstrated" however

histamine" leu0otriene " I/(histamine" leu0otriene " I/(have been detected?.have been detected?.


22/53

•

4emperature4emperature IgE"IgE"

histamine" chemotactichistamine" chemotactic

factors" 6" leucotrinefactors" 6" leucotrine

have been documented.have been documented.


23/53

• /ight/ight systemic lupussystemic lupus

erythematous" '# ;$ nm &erythematous" '# ;$ nm &

$$ #$$ nm" histamine &$$ #$$ nm" histamine &

chemotactic factors detectedchemotactic factors detected

after e5posure *+A & *+" #after e5posure *+A & *+" #

1$$ 0a. 1$$ 0a.


24/53

•

E5erciseE5ercise elevation of bloodelevation of blood

histamine" chemotactichistamine" chemotactic

factors" acetylcholinefactors" acetylcholine

receptors increased.receptors increased.


25/53

• 7tress7tress IC in8ection ofIC in8ection of

nonadrenalinnonadrenalin adrenergicadrenergic

urticaria.urticaria.

• @ater @ater blood histamine levelblood histamine level

were elevated & mast cellwere elevated & mast celldegranulation was presented.degranulation was presented.


26/53

Urticaria / angioedemaUrticaria / angioedemamediated by the complementmediated by the complement

system & other plasmasystem & other plasmaeffector systemeffectorsystem

• ,ereditary & ac=uired,ereditary & ac=uired

angioedemaangioedema there is athere is a

fungtional deficiency of thefungtional deficiency of theinhibitor of the activated ofinhibitor of the activated of

C1I2, & C;b.C1I2, & C;b.


27/53

• 2ecroti3ing venulitis2ecroti3ing venulitis

abnormalities of C1= & Ig%abnormalities of C1= & Ig%component.component.

• 9eactions to the administration9eactions to the administration

of blood productof blood product may arisemay arise

after imuni3ation by transfusionafter imuni3ation by transfusion

or by plasental tranferor by plasental tranferactivated Ig6 & ,ageman factoractivated Ig6 & ,ageman factor

fragments.fragments.


28/53

• InfectionsInfections hepatitis virushepatitis virus

infectioninfection

immune comple5-immune comple5-

mediated necroti3ing vasculitismediated necroti3ing vasculitis

with cryoglobulinemia.with cryoglobulinemia.

• Angiotensin converting en3ymeAngiotensin converting en3yme

inhibitorsinhibitors the mechanism notthe mechanism not

to be immunologic because theto be immunologic because thelesions occur within hours oflesions occur within hours of

the first dose.the first dose.


29/53

Laboratory findindsLaboratory findinds

• In all patient :In all patient :

,istory & physical,istory & physical

e5amination.e5amination.

rovocative test for physicalrovocative test for physical

urticarias.urticarias.


30/53

• In selected patients :In selected patients :

Complete blood count withComplete blood count with

differential analysis.differential analysis.

Erytrocyte sedimentationErytrocyte sedimentation

rate.rate.

*rinalysis.*rinalysis.

lood chemistry pofile.lood chemistry pofile.


31/53

7tool e5amination for ova &7tool e5amination for ova &

parasites.parasites.

Antinuclear factor.Antinuclear factor.

,epatitis & C virus surface,epatitis & C virus surface

Ag & Ab.Ag & Ab.

70in test for IgE-mediated70in test for IgE-mediated

reactions.reactions.


32/53

9adioallergosorbent test9adioallergosorbent test

>9A74? for specific IgE.>9A74? for specific IgE.

C,#$.C,#$.

Cryoproteins.Cryoproteins.

lasma & erythrocytelasma & erythrocyte

protoporphyris.protoporphyris.

70in biopsy.70in biopsy.


33/53

HistopathologyHistopathology

• olymorphous perivascularolymorphous perivascular

infiltrate.infiltrate.

•2eutrophils.2eutrophils.

• Eosinophils.Eosinophils.

• %ononuclear cells.%ononuclear cells.

• 7parse perivascular7parse perivascular

lymphocytes.lymphocytes.


34/53

PathologyPathology

• Chronic idiopathic urticariaChronic idiopathic urticaria

C" C'" 4 lymphocytes"C" C'" 4 lymphocytes"

neu" eusi detected by directneu" eusi detected by direct

immunofluorescence" %" -immunofluorescence" %" -

selectinselectin biopsy.biopsy.

• Acut urticariaAcut urticaria %" EC.%" EC.


35/53

• hysical urticariahysical urticaria C BC B

C'" neu" eosi with %" E-C'" neu" eosi with %" E-

selectin" +CA%selectin" +CA% by histologicby histologic

result.result.

•

7olar urticaria7olar urticaria

%" EC.%" EC.

• apular urticariaapular urticaria 4 lymp"4 lymp"

macrophages" eosi" neu.macrophages" eosi" neu.


36/53

• Chollergic urticariaChollergic urticaria %"%"

EC.EC.

• Chronic urticariaChronic urticaria E-E-

selectin" -selectin"selectin" -selectin"

intercellular adhesion mol 1"intercellular adhesion mol 1"

+CA%.+CA%.


37/53

Diagnosis &Diagnosis &Differential diagnosisDifferential diagnosis

• *rticaria & angioedema*rticaria & angioedema

episode & evanescent" seldomepisode & evanescent" seldom

persist for B ' h for severalpersist for B ' h for several

days.days.

• 7everal disorder are included in7everal disorder are included in

..


38/53

• Erythema multiformeErythema multiforme

edematous" papulovesicular"edematous" papulovesicular"bullous eruptions with mucosalbullous eruptions with mucosal

involvement" typical iris orinvolvement" typical iris or

target.target.

• /yme borreliosis/yme borreliosis annulerannuler

edematous" urticarial pla=uesedematous" urticarial pla=ues

may e5pand in diameter.may e5pand in diameter.


39/53

• ullous pemphigoidullous pemphigoid

edematous & erythematousedematous & erythematous

pla=ues.pla=ues.

• *rticaria pigmentosa*rticaria pigmentosa

generali3edgenerali3ed red-brown"red-brown"

macular" papular.macular" papular.


40/53

Treatment Treatment

4he ideal treatment for urticaria )4he ideal treatment for urticaria )

angioedema is identification &angioedema is identification &

removal of its cause.removal of its cause.


41/53

• ,1-type antihistamine drugs,1-type antihistamine drugs

mainstays.mainstays.

• 2ewer 2ewer low-sedating" reducelow-sedating" reduce

sedative" anticholinergic.sedative" anticholinergic.

• If this drug fails to be effectiveIf this drug fails to be effective

combination of agent fromcombination of agent from

different classes may be used.different classes may be used.


42/53

• Combination of ,1 & , may beCombination of ,1 & , may be

beneficial & 0etotifen has beenbeneficial & 0etotifen has been

used succesfullyused succesfully chronicchronic

urticariaurticaria reported >colchine inreported >colchine in

combination with ,1to becombination with ,1to be

benefit? & also cycsporine.benefit? & also cycsporine.


43/53

7ystemic glucocorticoid have no7ystemic glucocorticoid have no

place in regular therapy.place in regular therapy.

rednisone in management ofrednisone in management of

acute urticaria has beenacute urticaria has been

advocated in emergency rooms.advocated in emergency rooms.


44/53

• ral disodium cromoglycate isral disodium cromoglycate is

effectiveeffective food allergy.food allergy.• 4erbutaline" a4erbutaline" a -agonist in-agonist in

combination with an ,1-typecombination with an ,1-type

has been reported to be ofhas been reported to be of

benefitbenefit idiopathic urticariaidiopathic urticaria

failed from conventionalfailed from conventional

therapytherapy nefidipine.nefidipine.


45/53

• Immunoglobulin >I+? wasImmunoglobulin >I+? was

limited benefit & also trials waslimited benefit & also trials wasof was of benefit with >7C?of was of benefit with >7C?

interferon-interferon-

..

• Epineprine is widely usedEpineprine is widely used

particularly in hospitalparticularly in hospital

laryngeal edema" cardivascularlaryngeal edema" cardivascular

collapse.collapse.


46/53

• Antihistamine prophylacticAntihistamine prophylactic

physical urticaria.physical urticaria.

• 1D-1D-

-al0ylated androgen-al0ylated androgen

dana3oldana3ol reduction inreduction in

e5ercise provo0ed e5perimentale5ercise provo0ed e5perimental

whealswheals cholinergic urticaria.cholinergic urticaria.


47/53

• 27AIs" cetri3ine"27AIs" cetri3ine"

sulfasala3aline & syst.sulfasala3aline & syst.

6lucocorticoid6lucocorticoid delayeddelayed

pressure urticaria.pressure urticaria.

• 4erbutaline & aminophylline4erbutaline & aminophylline

combination" ,1 & ,1 comb.combination" ,1 & ,1 comb.

cold urticaria.cold urticaria.


48/53

• ropanolol hydrochlorideropanolol hydrochloride

adrenergic urticaria.adrenergic urticaria.

•

*+A phototherapy & *+A*+A phototherapy & *+A

photochemotherapyphotochemotherapy

physical urticaria.physical urticaria.


49/53

*rticaria ) angioedema may be a*rticaria ) angioedema may be a

source of frustration to bothsource of frustration to both

physician & patients" mostphysician & patients" most

patients can achieve acceptablepatients can achieve acceptable

symptomatic control of theirsymptomatic control of their

disease without identification ofdisease without identification ofthe cause.the cause.


50/53


51/53


52/53


53/53

Documents

Urticaria Angioedema Alwi