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The ins and outs of Hives- with apologies to bees!

The ins and outs of Hives- with apologies to bees!. Urticaria and Angioedema Richard J Powell. Simple urticaria. urticaria is Latin for nettle rash hives, welts, anywhere - trunk and limbs diverse morphology - wheal and flare pruritic with a central raised area erythematous halo

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The ins and outs of Hives- with apologies to bees!

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  1. The ins and outs of Hives-with apologies to bees! Urticaria and Angioedema Richard J Powell

  2. Simple urticaria • urticaria is Latin for nettle rash • hives, welts, • anywhere - trunk and limbs • diverse morphology - wheal and flare • pruritic with a central raised area • erythematous halo • blanch with pressure • Resolve within 24 hours -no residuum

  3. Angioedema with urticaria • same process, just deeper in tissues • occurs in extremities, digits, lips, eyelids, tongue, larynx, GI tract and genitals (in men) • painful rather than itchy

  4. Urticaria and angioedema • affects 15-20% • women > men • in majority it is acute and self-limiting • <10% become chronic • Urticaria with angioedema in 50% cases • 10% have angioedema alone • Rest have urticaria alone

  5. Classification of urticaria • cholinergic • contact • physical - exercise, aquagenic, dermatographism, cold, solar, delayed pressure • vasculitic

  6. Histamine release causes • Itching via nerve fibres • Redness - local capillary dilatation • Oedema - increased permeability

  7. Acute urticaria and angioedema-in primary care handled frequently and effectively • duration < 6 weeks • more common in children • acute self-limiting character limits morbidity • mast cell degranulation • aetiology is often elusive ? viral • Can be associated with isolated exposure to allergens (food, drugs, venom, latex) • non specifically (NSAIDs, codeine, radio-contrast dyes)

  8. Causes of acute urticaria and angioedema • Idiopathic • Peanuts, eggs, fish, milk, shellfish • Drugs - antibiotics, NSAIDs/aspirin • Latex and associated foods • Insect bites -wasp and bee venom, mosquitoes • Infections • Blood products and plasma expanders • Inhalant allergens- rare

  9. Chronic Urticaria and Angioedema -in primary care • 0.1% population • Duration >6 weeks • >50% resolve within 5 years • Rule out recurrent episodes of acute urticaria • Vexing problem • Often disabling, interfering with patient’s QOL • Worse at night - interrupts sleep

  10. Chronic Urticaria and Angioedema -in primary care • 50% autoimmune aetiology • Rarely a true allergy - SPT/elimination diets can help convince the patient that an allergen is not involved

  11. Angioedema without hives • Idiopathic • ACE inhibitors - bradykinin • Hereditary angio(neurotic)edema (HAE) - hence family history • Acquired angioedema

  12. Investigations • Diagnosis based on history • Headache/pain relief • Itching after intercourse, visiting dentists, balloons • Allergen specific IgE in vivo or in vitro • C4 and CI inhibitor • FBC and ESR • LFTs and TFT’s • Intra-dermal skin test with autologous serum

  13. Management • Avoid trigger if identified • H1 antihistamines - chronically for > 6 months • H2 antihistamines • Leukotriene receptor antagonists - monteleukast • T cell inhibitors if all else fails- cyclosporine (neoral) • Oral cortico-steroids • Rarely adrenaline • Referral for specialist opinion

  14. “Some patients with chronic urticaria do not respond to conventional doses of anti-histamines and much higher than licensed doses are often used (e.g. up to 20mg with cetirizine).” NEJM 346:175-179;2002 • “….in general it is better to achieve symptom control (and thereby a good night’s sleep) with a non-sedating preparation.” Drug and Therapeutics Aug 2002

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