Introduction:

UrticariaandAngioedemaUrticariaAngioedemaEtiologyofUrticarialReactions:

AllergicTriggersAcuteUrticariaDrugsFoodsFoodadditivesViralinfectionshepatitisA,B,CEpstein-BarrvirusInsectbitesandstingsContactantsandinhalants

(includesanimaldanderandlatex)ChronicUrticariaPhysicalfactorscoldheatdermatographicpressuresolarIdiopathicThePathogenesisofChronicUrticaria:

CellularMediatorsHistamineasaMastCellMediatorRoleofMastCellsinChronicUrticaria:

LowerThresholdforHistamineReleaseReleasethresholddecreasedby:Cytokines&chemokines

inthecutaneous

microenvironmentAntigenexposureHistamine-releasingfactorAutoantibodyPsychologicalfactorsReleasethresholdincreasedby:CorticosteroidsAntihistaminesCromolyn(invitro)CutaneousmasscellAnAutoimmuneBasisforChronic

IdiopathicUrticaria:AntibodiestoIgEInitialWorkupofUrticariaPatienthistorySinusitisArthritisThyroiddiseaseCutaneousfungalinfectionsUrinarytractsymptomsUpperrespiratorytractinfection

(particularlyimportantinchildren)Travelhistory(parasiticinfection)SorethroatEpstein-Barrvirus,infectious

mononucleosisInsectstingsFoodsRecenttransfusionswith

bloodproducts(hepatitis)RecentinitiationofdrugsPhysicalexamSkinEyesEarsThroatLymphnodesFeetLungsJointsAbdomenLaboratoryAssessmentfor

ChronicUrticariaPossibletestsforselectedpatientsStoolexaminationforova

andparasitesBloodchemistryprofileAntinuclearantibodytiter(ANA)HepatitisBandCSkintestsforIgE-mediated

reactionsInitialtestsCBCwithdifferentialErythrocytesedimentationrateUrinalysisRASTforspecificIgEComplementstudies:CH50CryoproteinsThyroidmicrosomalantibodyAntithyroglobulinThyroidstimulatinghormone(TSH)HistopathologyGroup2:PolymorphousperivascularinfiltrateNeutrophilsEosinophilsMononuclearcellsGroup3:SparseperivascularlymphocytesUrticariaAssociatedWith

OtherConditionsCollagenvasculardisease(eg,systemiclupuserythematosus)Complementdeficiency,viralinfections(includinghepatitisB

andC),serumsickness,andallergicdrugeruptionsChronictineapedisPruriticurticarialpapulesandplaquesofpregnancy(PUPPP)Schnitzler’ssyndromeH1-ReceptorAntagonists:

ProsandConsforUrticariaandAngioedemaFirst-generationantihistamines(diphenhydramine

andhydroxyzine)Advantages:Rapidonsetofaction,relativelyinexpensiveDisadvantages:Sedating,anticholinergicSecond-generationantihistamines(astemizole,

cetirizine,fexofenadine,loratadine)Advantages:Nosedation(exceptcetirizine);noadverse

anticholinergiceffects;bidandqddosingDisadvantages:ProlongationofQTinterval;ventricular

tachycardia(astemizoleonly)inapatientsubgroupFour-weekTreatmentPeriod:

FexofenadineHClMeanPruritusScores/MeanNumberofWheals/MeanTotalSymptomScoresAnApproachtotheTreatmentof

ChronicUrticariaTreatmentofUrticaria:

PharmacologicOptionsAntihistamines,othersFirst-generationH1Second-generationH1Antihistamine/decongestant

combinationsTricyclicantidepressants

(eg,doxepin)CombinedH1andH2agentsBeta-adrenergicagonistsEpinephrineforacuteurticaria

(rapidbutshort-livedresponse)TerbutalineCorticosteroidsSevereacuteurticariaavoidlong-termuseusealternate-dayregimen

whenpossibleAvoidinchronicurticaria

(lowestdoseplusantihistamines

mightbenecessary)MiscellaneousPUVAHydroxychloroquineThyroxineAtopicDermatitis:Acute,Subacute,

andChronicLesionsAcuteCutaneousLesionsErythematous,intenselypruriticpapulesandvesiclesConfinedtoareasofpredilectioncheeksininfantsantecubitalpoplitealSubacuteCutaneousLesionsErythemaexcoriation,scalingBleedingandoozinglesionsChronicLesionsExcoriationswithcrustingThickenedlichenifiedlesionsPostinflammatoryhyperpigmentationNodularprurigoAtopicDermatitis:

PhysicalDistributionbyAgeGroupImmuneResponseinAtopicDermatitisMarkedlyelevatedserumIgElevelsPeripheralbloodeosinophiliaHighlycomplexinflammatoryresponses>IgE-dependent

immediatehypersensitivityMultifunctionalroleofIgE(beyondmediationofspecific

mastcellorbasophildegranulation)CelltypesthatexpressIgEonsurfacemonocyte/macrophagesLangerhans’cellsmastcellsbasophilsAtopicDermatitis:

TeststoIdentifySpecificTriggersSkinpricktestingforspecificenvironmental

and/orfoodallergensRAST,ELISA,etc,toidentifyserumIgEdirectedtospecific

allergensinpatientswithextensivecutaneousinvolvementTzancksmearforherpessimplexKOHpreparationfordermatophytosisGram’sstainforbacterialinfectionsCultureforantibioticsensitivityforstaphylococcalinfection;

supplementwithbacterialculturesCulturestosupporttestsbacterial,viral,orfungalTopicalCorticosteroidsRankedfromhightolowpotencyin7classesGroup1(mostpotent):betamethasonedipropionate0.05%Group4(intermediatepotency):hydrocortisonevalerate0.2%Group7(leastpotent):hydrocortisonehydrochloride1%Localsideeffects:

Developmentofstriaeandatrophyoftheskin,perioral

dermatitis,rosaceaSystemiceffects:

Dependonpotency,siteofapplication,occlusiveness,

percentageofbodycovered,lengthofuseMaycauseadrenalsuppressionininfantsandsmallchildren

ifusedlongtermAntihistaminesandOtherTreatmentsStan