2. Chronic Urticaria & Angioedema successfully treated by Thyroxin Thaer Douri, M.D, Dermatologist, Hama - Syria

3. Case Report A woman aged 30 years, Pharmacist, presented with a three years history of urticaria & angioedema which was treated previously by the classical treatment without benefit.

4. Paraclinical Studies Routine laboratory investigation : Normal ANA, C1, C4, C3 : Normal. Abdominal Echogarphy : Normal. Chest X-Ray : Normal.

5. The patient was initially treated by: Antihistamines, Unicycline, Nystatine, Diet. Transient improvement Follow up Although T3, TSH were normal, We decided to treat the patient by L - Thyroxin 100 microgram daily.

6. RESULT Magic improvement. The patient was symptom- free during treatment. Recurrence when the patient stopped the treatment.

7. Review of Medical Literature

8. Angioedema Causes : 1-Food. 2-Drugs. 3-Hereditary. 4-Idiopathic.

9. Hereditary angioedema HAE 3 types : 1- plasma concentration of c1-inhibitor are 5-30% of normal, and C4 concentration is low 2-C1-inhibitor normal or raised, bet it is dysfunctional, and C4 concentration is low. 3-both of C1-inhibitor,and C4 concentration are normal The clinical features of three variants of HAE are similar. YEAR BOOK OF DERMATOLOGY 2001 P59

10. Management of chronic urticaria remove identifiable cause Non drug therapy pharmacological therapy J.A.A.D May 2002

11. Non drug therapy General advice: cooling lotion Avoidance aggravating factor : avoid aspirin,NSAIDs,codein,morphine,ACE inhibitors – minimize stress,overheating, alcholic. Diet J.A.A.D May 2002

12. pharmacological therapy First line non or low sedating H1 antihistamine. Add sedating H1 antihistamine at night. Add H2 antagonist J.A.A.D May 2002

13. pharmacological therapy second line Corticosteroids ( short term use only ) Epinephrine (severe throat angioedema or anaphlaxis) Other J.A.A.D May 2002

14. pharmacological therapy Third line Immunotherapy J.A.A.D May 2002

15. Leznoff described (1) : 140 cases of urticaria, 17 ( 12,1 % ) have elevated ( ANTIBODY MICROSOMAL THYROID ), 8 patients have a goiter or thyroid dysfunction, 17 angioedema ( 15 f ), Control : 447, only 27 ( 5,6%) have (ANTIBODY MICROSOMAL THYROID ). J. A. D FEBRAURY 1999. P 229

16. Leznoff described (2) : 90 patients of 624 (14,4 %), with chronic Urticaria & Angioedem have thyroid autoimmunity disease, Control only (6%). J. A. D FEBRAURY 1999. P 229

17. Gazi university, Turkey : 94 with Urticaria & Angioedema were studied, 11 (11,7%) have ( Thyroglobulin antibodies ) 9 (9,75%) have ( Thyroid microsomal antibodies). 6 of 11 have thyroid dysfunction, and 5 were euthyroid, Control :( 80 ) only( 3,7%) have both antibodies. Int J Dermatol 1997 Mar;36(3):187-90

18. Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity. Antithyroglobulin and antiperoxidase antibodies were measured in 170 consecutive patients with CIU. Twenty-five (14.7%) had an antithyroglobulin or antiperoxidase antibody levels > 180 lU/ml and all but three were women. J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5

19. Twenty patients with CIU and thyroid autoimmunity were treated with levothyroxine sodium if hypothyroidism or normal thyroid function were present (18 patients) and with methimazole if hyperthyroidism was detected (two patients) J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5 Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity.

20. Urticaria resolved rapidly in two patients with Graves' disease. The clinical response of urticaria to levothyroxine sodium treatment was good in 15 patients and partial in two, whereas only one patient showed no improvement in clinical score (p < 0.0005). No changes in the antithyroglobulin or antiperoxidase levels were detected. J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5 Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity.

21. REMARKS The mechanism by which thyroid autoimmunity is associated with Urticaria is poorly understood. L - Thyroxin was used to treat (C.U.A) for the first time by Leznoff in 1983. The mechanism is an enigma. Hyperthyroidism and Hypothyroidism may be the cause of itching. L-Thyroxin may cause Urticaria. J. A. D FEBRAURY 1999. P 229

22. GUIDELINE TREATMENT Screen for Thyroid autoimmunity, Treatment with L - Thyroxin for (CUA) unresponsive for classical treatment. T.S.H should be monitored after 4-6 weeks of the initiation of therapy. If there is no benefit after 8 weeks, L- Thyroxin should be stopped. The treatment must be stopped after 1-2 months of recovery and reinitiated in the case of relapse J. A. D FEBRAURY 1999. P 229

23. REFERENCES J.A.A.D May 2002. J. A. D FEBRAURY 1999. P 229. Int J Dermatol 1997 Mar;36(3):187-90. YEAR BOOK OF DERMATOLOGY 2001 P59. J Investig Allergol Clin Immunol 2000 Nov- dec;10(6):342 -5

24. Thank you