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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


8 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)

9 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

10 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

11 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

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

13 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

14 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

15 “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: ;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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