Mina Saber, MD Assistant Professor of Dermatology

Mina Saber, MD Assistant Professor of Dermatology
Review of Dermatology Mina Saber, MD Assistant Professor of Dermatology

Common skin Disorders Urticaria and angioedema Pruritus Acne vulgaris
Fingal disease Wart

Urticaria and Angioedema
15-20% of population experience at least one episode of urticaria during lifetime Acute urticaria 6w> vs chronic urticaria 6w<

Urticaria and Angioedema Ethiology
Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1%

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticaria Cold contact urticaria Cholinergic urticaria

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism ~ 5% of normal papulation No association with systemic disease, atopy food allergy or autoimmunity

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticaria Deep erythematouse swellings at sites of sustained pressure to the skin Delay of 30 min to 12 h pruritic, painful or both May persist for several days

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticaria Most cases are idiopathic but may follow respiratory infection and bites Itching, burning and whealing in cold-exposed area minutes after rewarming Potential risk of anaphylaxis with cold bath and swimming

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticarial Multiple small paular wheals with obvious flare Within 15 min of sweating inducing stimuli

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria Vasculitis 5% Ordinary 60% Autoimmune pseudoallergic Infection-related idiopathic

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria Vasculitis 5% > 24 hours Painful and burning sensation as well as pruritus Residual purpura Often occur at pressure point Concurrent angioedema up to 40% Extra cutaneous manifestations (arthralgia, abdominal pain, COPD and ….)

Common causes of acute urticaria Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Cause of chronic urticaria Physical 35% Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria Vasculitis 5% Ordinary 60% Autoimmune pseudoallergic Infection-related Idiopathic

Urticaria and Angioedema Clinical Presentation
Clinical presentation of wheal Firm, edematouse plaque that is evanescent and pruritic Generally last less than 24 hours

Clinical presentation of wheal Firm, edematous plaque that is evanescent and pruritic Generally last less than 24 hours Angioedema Abrupt and short-lived swelling of the skin and mucouse membranes In 50% of cases associated with urticaria

Clinical presentation of wheal Firm, edematous plaque that is evanescent and pruritic Generally last less than 24 hours Angioedema Abrupt and short-lived swelling of the skin and mucous membranes In 50% of cases associated with urticaria Angioedema without wheal Idiopathic (many cases) Drug reaction (NSAIDs and ACE inhibitors) C1 inhibitor deficiency (inherited or acquired)

Clinical presentation of wheal Firm, edematouse plaque that is evanescent and pruritic Generally last less than 24 hours Angioedema Abrupt and short-lived swelling of the skin and mucouse membranes In 50% of cases associated with urticarial Angioedema without wheal Idiopathic (many cases) Drug reaction (NSAIDs and ACE inhibitors) C1 inhibitor deficiency (inherited or acquired)

Urticaria vs Angioedema

Subcutaneous and submucosal surface Urticaria Epidermis and dermis

Subcutaneous and submucosal surface Last hours Urticaria Epidermis and dermis Last < 24 hours

Subcutaneous and submucosal surface Last hours Often accompanied with pain and tendernes Urticaria Epidermis and dermis Last < 24 hours Associated with pruritus

Urticaria and Angioedema
For acute or episodic urticaria no investigations are required except where suggested by the history Chronic urticaria refer to dermatologist

Urticaria and Angioedema Intervention
General measures Stop nonspecific aggravating factors Overheating Stress Alcohol Drugs (aspirin and codein)

General measures Stop nonspecific aggravating factors Overheating Stress Alcohol Drugs (aspirin and codein) NSAIDs avoided in aspirin-sensitive patients with urticaria

General measures Stop nonspecific aggravating factors Overheating Stress Alcohol Drugs (aspirin and codein) NSAIDs avoided in aspirin-sensitive patients with urticaria ACE inhibitors avoided in patients with angioedema without wheal and with caution in urticaria + angioedema

General measures Stop nonspecific aggravating factors Overheating Stress Alcohol Drugs (aspirin and codein) NSAIDs avoided in aspirin-sensitive patients with urticarial ACE inhibitors avoided in patients with angioedema without wheal and with caution in urticaria + angioedema Estrogen avoided in hereditary angioedema

General measures Topical treatments Topical steroids (poor evidence) Cooling antipruritic lotions Calamine Menthol 1%

Urticaria and Angioedema Pharmacological Agents (AHs)
Stage 1 Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria

Urticaria and Angioedema Pharmacological Agents
Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h

Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h 40% of patients response to AHs

Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h 40% of patients response to AHs Hydroxyzine is the most potent of the classical AHs

Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Non-sedative AHs

Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Chlorpheniramine Cyproheptadine Hydroxyzine Ketotifen Promethazine Non-sedative AHs

Antihistamins (AH) H1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1-3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Chlorpheniramine Cyproheptadine Hydroxyzine Ketotifen promethazine Non-sedative AHs Cetrizine Fexofenadine Loratadine Levocetrizine Desloratadine

Use of classical AHs is limited by their side effects

Use of classical AHs is limited by their side effects First line is non-sedating AHs

Use of classical AHs is limited by their side effects First line is non-sedating AHs Control the symptoms but not influence the disease course

Use of classical AHs is limited by their side effects First line is non-sedating AHs Control the symptoms but not influence the disease course Individual response is variable

Use of classical AHs is limited by their side effects First line is non-sedating AHs Control the symptoms but not influence the disease course Individual response is variable If one AH dose not work it is worth trying another

If little or no response Increase above licensed dose and add sedating AH at night

If little or no response increase above licensed dose and add sedating AH at night Recent international consensus

If little or no response increase above licensed dose and add sedating AH at night Recent international consensus Increase the dose of second generation AHs up to 4 fold above license in adults when lower dose do not provide adequate symptom control

Stage 2

Stage Add H2 antagonist

Stage Add H2 antagonist Evidence is poor and not all authorities recommend this therapeutic approach

Stage Add H2 antagonist Evidence is poor and not all authorities recommend this therapeutic approach Ranitidine is preferable

Urticaria and Angioedema Pharmacological Agents (Combination Therapy)
Stage Targeted intervention

Stage Targeted intervention Prednosolone

Stage Targeted intervention Prednosolone 30-50 mg/day

Stage Targeted intervention Prednosolone 30-50 mg/day Short time management of urticarial crisis and serious angioedema

Stage Targeted intervention Prednosolone 30-50 mg/day Short time management of urticarial crisis and serious angioedema Avoid regular treatment

Stage Targeted intervention Prednosolone 30-50 mg/day Short time management of urticarial crisis and serious angioedema Avoid regular treatment Rebound is common problem

Stage Targeted intervention Prednosolone 30-50 mg/day Short time management of urticarial crisis and serious angioedema Avoid regular treatment Rebound is common problem Long-term course of the urticaria is often not altered

Stage Targeted intervention Epinephrine

Stage Targeted intervention Epinephrine SC or IM for anaphylactic shock or severe anaphylactoid reactions

Stage Targeted intervention Epinephrine SC or IM for anaphylactic shock or severe anaphylactoid reactions Angioedema of oropharynx and severe acute allergic urticaria

Stage Targeted intervention Epinephrine SC or IM for anaphylactic shock or severe anaphylactoid reactions Angioedema of oropharynx and severe acute allergic urticaria Not effective for hereditary angioedema

Stage Targeted intervention Doxepin

Stage Targeted intervention Doxepin TCA with very potent H1 and H2 AH properties

Stage Targeted intervention Doxepin TCA with very potent H1 and H2 AH properties Leukoteriene inhibitors

Stage Targeted intervention Doxepin TCA with very potent H1 and H2 AH properties Leukoteriene inhibitors Benefit in aspirin sensitive urticaria

Stage Targeted intervention Doxepin TCA with very potent H1 and H2 AH properties Leukoteriene inhibitors Benefit in aspirin sensitive urticaria Montelukast is usually chosen

Urticaria and Angioedema Pharmacological Agents (Immunosuppresive)
Stage specialist use only

Stage specialist use only Immunotherapy

Stage specialist use only Immunotherapy Plasmapheresis

Stage specialist use only Immunotherapy Plasmapheresis IVIG infusion

Stage specialist use only Immunotherapy Plasmapheresis IVIG infusion Cyclosporine

Stage specialist use only Immunotherapy Plasmapheresis IVIG infusion Cyclosporine Omalizumab

Common skin Disorders Urticaria and angioedema Pruritus Acne vulgaris
Fingal disease Wart

Mina Saber, MD Assistant Professor of Dermatology

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Mina Saber, MD Assistant Professor of Dermatology

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