Physical urticaria is a heterogeneous group of inducible conditions that includes symptomatic dermographism, cold contact urticaria, heat contact urticaria, delayed pressure urticaria, and others. Symptomatic dermographism is the most common subtype, where mechanical stroking of the skin causes a wheal and flare reaction with itch. Cold contact urticaria is triggered by skin contact with cold stimuli and can be diagnosed using an ice cube test. Treatment involves avoidance of physical triggers as well as antihistamines. For severe cases that are resistant to antihistamines, immunosuppressants or intravenous immunoglobulins may be considered.

1. Physical Urticaria
Theerapan Songnuy
Dec 7, 2012

2. Overview
• Definition
• Epidemiology
• Classification
• Diagnosis
• Treatment

3. Urticaria
Urticaria :
- The appearance of pruritic,erythematous
skin elevation which blanch with pressure
- Small venules & capillaries dilation in
superficial dermis
- Collagen fiber swelling
Angioedema :
- similar pathologic reaction
- Involves deep dermis & subcutaneous tissue
- Fewer mast cell & sensory nerve ending
- More painful or burning sensation than pruritus
- Often on face, tongue ,genitalia & extremities
Middleton’s Allergy 7th Edition

4. Physical Urticaria
• A heterogeneous group of inducible conditions
that includes:
- Symptomatic dermographism/urticaria
factitia
- Cold contact urticaria
- Heat contact urticaria
- Delayed pressure urticaria
- Vibratory urticaria /angioedema
- Solar urticarias
- Aquagenic urticaria
- Contact urticaria
- Exercise induced urticaria /anaphylaxis
Allergy 2009; 64 (12): 1715-1721

5. Physical Triggers
• Symptomatic dermographism / Urticaria factitia : mechanical
stroking
• Cold contact urticaria : skin contact with cold air/water/solids
• Heat contact urticaria : skin contact with hot air/water/solids
• Delayed pressure urticaria: vertical sustained pressure
• Vibratory urticaria/angioedema : vibration (e.g. pneumatic
hammer)
• Solar urticaria : UV and/or visible light
• Aquagenic urticaria : water contact at any temperature
• Contact urticaria : contact with an allergic or nonallergic
stimulus
• Exercise induced urticaria /anaphylaxis : physical exercise
• Cholinergic urticaria : increased core body temperature
Allergy 2009; 64 (12): 1715-1721

6. Epidemiology
• Urticaria
- The life-time prevalence of any subtype is 20%
• Physical urticaria
- prevalence 20% of chronic urticaria
- In children prevalence ranges from 6.2-25.5%
Allergy 2009;64: 1417-1426
Ann Allergy 1993:71:205-12
Ann Allergy 1992; 69: 61-65

8. Aim: To study the prevalence, type, clinical data &
natural history of physical urticaria including
prognostic factors for remission
Material & Methods :
- A retrospective study
- The Dermatologic Unit, Siriraj Hospital
- Jan 2003-Dec 2008
- Patients aged above 18 years
- Demographic data, causes of
urticaria, associated diseases, physical
exammination, lab etc.
JEADV 2011 ; 25: 1194-1199.

9. • Tests to categorize type
- Dermographometer ( pressure at 4900 g/cm2 )
- Delayed-pressure ( sandbags 15 lbs over one
shoulder for 15 min) then observe 2-8 hr. later
- Cold urticaria ( Ice-cube test, place ice inside plastic bag on
forearm 10 min then observe 15 min later
- Cholinergic ( run until exhausted & sweaty ) then
observe within 15 min
- Adrenergic ( ID noradrenalin 3-10 ng in 0.02 ml saline
observe erythematous papule & halo )
JEADV 2011 ; 25: 1194-1199.

10. • Tests to categorize type
- Solar urticaria ( photo test with visible light
UVA, UVB )
- Others ; CBC, UA, ESR, ANA, cryoglobulin
HBsAg, anti-HCV Ab etc.
Remission: non-urticarial wheal for at least 6
months after stop medication & negative test
JEADV 2011 ; 25: 1194-1199

11. JEADV 2011 ; 25: 1194-1199

12. JEADV 2011 ; 25: 1194-1199

13. JEADV 2011 ; 25: 1194-1199

14. JEADV 2011 ; 25: 1194-1199

15. • From chronic urticaria: physical urticaria was 7.2%
• The most common type is symptomatic dermographism
• Only 13.9% associated with chronic spontaneous urticaria
• No multiple types of physical urticaria
• ESR was the most common abnormal labs
• The median time after onset before 50% remission
- Cholinergic urticaria took the shortest course
- Delayed-pressure took the longest period
- After 1 y & 5 y from onset of symptom, 13 % & 50%
of physical urticaria were free of symptoms

16. Symptomatic Dermatographism
• Syn : urticaria factitia, dermographic urticaria
• The most common subtype of physical urticaria
• Has to be differentiated from simple
Dermographism where wealing, but not
pruritus, occurs after moderate stroking of the
skin
• Develope itching & wealing at a lower force
than that required to induce simple
dermographism
• Other types of dermographism such as white
dermographism (in atopic patients) are
unrelated to symptomatic dermographism
Immunol Allergy Clin North Am2004;24:225–246.

17. Symptomatic Dermatographism
• Provocation testing
- A dermographometer : to apply a rubbing stimulus to a subject’s skin
using predefined and reproducible pressures
- A calibrated dermographometer is commercially available (HTZ
Limited, Vulcan Way, New Addington, Croydon, Surrey, UK)
- It has a spring-loaded smooth steel tip 0.9 mm in diameter. The
pressure on the tip can be varied by turning a screw at the top of the
instrument.
- The scale settings from 0 to 15 ( tip pressures from 20 to 160 g/mm2 )
Immunol Allergy Clin North Am2004;24:225–246.

18. Figure 3 Dermatographism. Linear stroking of skin
elicits a wheal within several minutes.
The American Journal of Medicine 2008; 121 ( 5) : 379 - 384

19. Symptomatic Dermatographism
• Diagnosis of symptomatic dermographism
-the smooth blunt object should be held
perpendicular to and used to apply a light
stroking pressure to the skin of the upper back
or volar forearm
- The skin at the test site should be unbroken
and free of obvious signs of infection
-Three parallel lines (up to 10 cm long)
should be made with dermographometer
settings equivalent to 20, 36 and 60 g/mm2.
Immunol Allergy Clin North Am2004;24:225–246.

20. Symptomatic Dermatographism
• The positive reaction : showing a wheal
response & report pruritus at the site of
provocation at 36 g/mm2 (353 kPa) or less
• A wheal response without itch on provocation
at 60 g/mm2 (589 kPa) or higher indicates
simple dermographism
• The test response should be read 10 min after
testing
J Am Acad Dermatol2008;59:752–757.

21. Management of Symptomatic
Dermatographism
• Diphenhydramine or hydroxyzine 25-50
mg. qid for severe patient
• Non-sedating antihistamine in mildly to
moderately severe cases, can be triple
the usual dose
Middleton’s Allergy 7TH Edition

24. Conclusion
• Cyclosporin may be worth trying for
antihistamine-resistant DU, especially in
those patient cases characterized by
severe itching
. Further studies on a larger scale are
expected to be conducted in order to
generate stronger levels of clinical
evidence.

25. Cold Urticaria & Related
Disorders
• Trigger by a cold stimulus ; wind, liquid
holding cold objects
• Total body exposure can lead to hypotension
( swimming)
• Disease begin in any age group, young adult
• “Ice-cube Test” placing a plastic containing ice
cube inside on patient’s forearm for 4 min, then
observe 10 min
Middleton’s Allergy 7th Edition

26. Cold Urticaria
• Positive : a palpable & clearly visible weal & flare reaction
with itchy and/or burning sensation
• In a positive test reaction, threshold testing should be
performed
• Threshold level may help patients to avoid risky situations and
their physician to optimize treatment
• Determining the stimulation time threshold, which is the
shortest duration of cold exposure required to induce a
positive test reaction
• Temperature thresholds, i.e. the highest temperature sufficient
to induce a positive test reaction, can be assessed with
TempTest
J Allergy Clin Immunol1986;78:417–423.

27. Cold-Dependent Syndromes
• Idiopathic cold urticaria
• Systemic cold urticaria( ice cube test negative) sensitive
to cold air
• Cold-induced cholinergic urticaria
• Cold-dependent dermographism
• Delayed cold urticaria ( edema, pain)
• Localized cold urticaria ( previous insect stinging)
• Cold reflex urticaria
• Associated with abnormal serum protein
- cryoglobulinemia
- cold agglutinin disease
- cryofibrinogenemia
- paroxysmal cold hemoglobinuria
Middleton’s Allergy 7th Edition

28. Cold Urticaria
• Mediators releasing from mast cell
- histamine
- PAF
- LTE2
- Prostaglandin D2
- TNF-alpha
- IL-3
Middleton’s Allergy 7th Edition

29. Management of Cold Urticaria
• Avoidance
• Cyproheptadine is the drug of choice
• Non-sedating H1 antihistamine
• For patient where IgE has a
role, monoclonal IgG anti-IgE may be
effective
Middleton’s Allergy 7th Edition

30. Atopic dermatitis and skin disease
High-dose desloratadine decreases wheal
volume and improves cold provocation
thresholds compared with standard-dose
treatment in patients with acquired cold
urticaria
: A randomized, placebo-controlled, crossover
study
Frank Siebenhaar, MD, Franziska Degener, MD,Torsten
Zuberbier, MD, Peter Martus, PhD,andMarcus Maurer, MD
Berlin, Germany
J Allergy Clin Immunol 2009;123:672-9

31. - Aim: assess the effects of 5 and 20 mg of
desloratadine and placebo on cold-induced
urticarial reactions in patients with acquired
cold urticaria (safety & efficacy)
- A prospective, double-
blind, randomized, placebo-controlled
crossover study
J Allergy Clin Immunol 2009;123:672-9

32. • Materials & Methods
- OPD of urticaria specialty clinic of the Allergie-
Centrum-Charite´ of the Charite´-
Universita¨tsmedizin, Berlin, Germany
- Patients aged 18 to 75 years with a confirmed
diagnosis of Acquired Cold Urticaria , made at least
6 week before
- Signs/symptoms were assessed by using the
Acquired Cold Urticaria Severity Index (ACUSI), &
triggering stimuli, previous medication use, and
concomitant disease
J Allergy Clin Immunol 2009;123:672-9

33. J Allergy Clin Immunol 2009;123:672-9

34. J Allergy Clin Immunol 2009;123:672-9

35. J Allergy Clin Immunol 2009;123:672-9

36. J Allergy Clin Immunol 2009;123:672-9

37. B, Example of thermographic images of the cold-induced wheal response over
20 minutes in a patient with ACU treated with placebo, 5 mg/d and 20 mg/d
desloratadine for 7 days
J Allergy Clin Immunol 2009;123:672-9

38. J Allergy Clin Immunol 2009;123:672-9

39. J Allergy Clin Immunol 2009;123:672-9

40. J Allergy Clin Immunol 2009;123:672-9

41. J Allergy Clin Immunol 2009;123:672-9

42. Conclusion
Treatment with desloratadine at doses of
5 and 20 mg daily significantly
decreased wheal volume/size
, improved CTTs & CSTTs in patients with
ACU
Treatment with the higher dose of
desloratadine yields higher outcomes in
wheal volume and CTTs and CSTTs
comparing with standard-dose
desloratadine

43. Solar Urticaria Treated With
Intravenous Immunoglobulins
HenriAdamski,MD, Christophe Bedane, MD, Annie
Bonnevalle, MD, Pierre Thomas, MD, Jean-Louis Peyron, MD, Bernard
Rouchouse, MD, Frederic Cambazard, MD, Michel
Jeanmougin, MD,and Manuelle Viguier, MD
Rennes, Limoges, Lille, Montpellier, Saint-Etienne, and Paris, France
J Am Acad Dermatol 2011;65:336-40

44. Solar urticaria treated with
intravenous immunoglobulins
• To report the effectiveness of intravenous immunoglobulins
(IVIG) in severe solar urticaria ( SU)
• A retrospective multicentric study via the mailing of a
questionnaire to the French Photodermatology Units
• Severe SU was defined as having a poor response to
antihistamine use and impairment of the quality of life
(impact on daily and professional life)
• Collected age, sex, medical history, medications, clinical
features, pho-tobiological characteristics, laboratory
investiga-tions, and clinical response to IVIG
J Am Acad Dermatol 2011;65:336-40

45. Table 1 Characteristics of patients before receiving IVIG
J Am Acad Dermatol 2011;65:336-40

46. Table 1 Characteristics of patients
before receiving IVIG
J Am Acad Dermatol 2011;65:336-40

47. J Am Acad Dermatol 2011;65:336-40

48. J Am Acad Dermatol 2011;65:336-40

49. Solar Urticaria
- A rare idiopathic photodermatosis
- Sun avoidance and antihistamine
- Severe solar urticaria needs more modality
such as
intravenous immunoglonulins
- Further trials are needed

50. Thank You Very Much