Chronic inducible urticaria

Author: Donna Bartlett, Medical Writer, Allori, Melbourne, Victoria, Australia. DermNet Editor in Chief: Adjunct A/Prof Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. December 2018.

This article was supported by an educational grant from Novartis, distributors of Xolair™ in New Zealand and Australia. Xolair is not indicated for the treatment of chronic inducible urticaria in either country. Sponsorship does not influence content.


What is urticaria?

Urticaria is a condition characterised by the presence of hives/weals (also spelt wheals) or angioedema (swelling in the skin) [1,2].

  • A weal is a superficial red or pale swelling in the skin and is often surrounded by erythema. A weal can persist from a few minutes to 24 hours.
  • Angioedema is a deeper skin-coloured or red swelling within the skin or mucous membranes. It can take up to 72 hours to resolve.

Urticaria affects up to 1 in 4 people at some time in their lives and is classified by duration (acute or chronic) and cause (spontaneous or inducible) [1–3].

Acute urticaria is the daily or episodic occurrence of weals, angioedema or both, for less than six weeks [1,2]. Causes can include infections and allergies, but more often the cause is unknown [2].

Figure 1. Classification of urticaria
Types of urticaria

What is chronic urticaria?

Chronic urticaria is the daily or episodic occurrence of weals (hives), angioedema or both for six weeks or more [1,2]. Chronic urticaria can persist for a few months to many years [2,4].

International guidelines have recently been published for the classification, diagnosis and management of chronic urticaria, based on a consensus from multiple national and international societies [1].

Chronic urticaria is either spontaneous or inducible; both types may co-exist in one patient [1,2]. See DermNet NZ's page on chronic spontaneous urticaria.

What is chronic inducible urticaria?

Chronic inducible urticaria is chronic urticaria that has an attributable cause or trigger and is classified according to the stimulus that provokes weals to develop. Commonly, these are stroking or scratching the skin (dermographism), or following exercise or emotional upset (cholinergic urticaria).

Less common forms of chronic inducible urticaria are triggered by cold, heat, pressure, sunlight (solar urticaria), contact with water or various chemicals (contact urticaria), or vibration [1,2].

Who gets chronic inducible urticaria?

Chronic urticaria is reported to affect 1.8% of the population [2]. The prevalence of chronic inducible urticaria is approximately 0.5% (15–25% of all cases of chronic urticaria) [3].

Women experience urticaria and chronic urticaria almost twice as often as men [2,4]. Although urticaria is common in children, they are more likely to present with chronic spontaneous urticaria than with chronic inducible urticaria [2].

What are the clinical features of chronic inducible urticaria?

Chronic inducible urticaria usually presents with weals [1,2]. Weals can appear on any site of the body [2,5].

  • They range in size from a few millimetres to several centimetres.
  • They are white or red and are often surrounded by a red flare.
  • In chronic inducible urticaria, weals generally appear about 5 minutes after the stimulus and last from a few minutes up to two hours [5].
  • The weals may change shape before resolving — they may be round, form rings or a map-like pattern.

Characteristically, weals are:

Angioedema can very rarely be induced within a few minutes of exposure to a vibratory stimulus [5]. Delayed pressure can lead to urticaria and angioedema.

Symptoms are usually confined to skin areas that are exposed to the specific trigger. Individual patients may exhibit two or more subtypes of chronic inducible urticaria [6].

Inducible urticaria

What causes chronic inducible urticaria?

Urticaria is a mast cell-driven disease. Activated mast cells release histamine along with other mediators, such as platelet activating factor (PAF) and cytokines, resulting in sensory nerve activation, vasodilation, plasma extravasation and recruitment of cells to the urticarial lesion. Mast cells can be activated by many different molecules in urticaria, but generally, these are not well defined [1].

Weals and angioedema are induced by environmental or physical stimuli in chronic inducible urticaria [1,2]. Different types of inducible urticaria and their triggers include:

  • Dermographism — scratching or tight clothing
  • Cold urticaria — cold air, cold water, ice, or cryotherapy
  • Cholinergic urticaria — increased body heat due to exercise, emotional upset, or a hot shower
  • Contact urticaria — a trigger substance absorbed through the skin or mucous membrane; this can be an allergen (IgE mediated), a pseudo-allergen, or an irritant (such as medicine, stinging nettle, or a hairy caterpillar)
  • Delayed pressure urticaria — pressure on the affected area several hours earlier, such as from a heavy bag, a seat belt, or sitting on a horse
  • Solar urticaria — exposure to sunlight, mainly affecting skin that is infrequently exposed to the sun
  • Heat urticaria — hot water bottle or a hot drink
  • Aquagenic urticaria or angioedema — water
  • Vibratory angioedema — a jackhammer, lawn mowing, motorcycle riding.

What are the complications of chronic urticaria?

The burden of chronic urticaria is substantial for patients, their families and carers, the health care system and society [1,3]. Chronic urticaria can result in sleep deprivation, anxiety, depression, lack of energy and social isolation [7] and result in significant deterioration in the quality of life [1,3].

How is chronic inducible urticaria diagnosed?

Chronic inducible urticaria is diagnosed by history and examination and is based on a history of daily or episodic weals for more than six weeks that have been induced by an external stimulus.

International guidelines provide a diagnostic algorithm for chronic urticaria (see Figure 3). The diagnosis of chronic inducible urticaria relies on provocation testing and compiling a thorough history, covering:

  • When the urticaria began
  • The shape, size, frequency and the distribution of the weals
  • Presence of angioedema
  • Presence of bone or joint pain, fever, or abdominal pain
  • A prior or family history of weals and angioedema
  • Whether the weals are induced by physical agents or exercise
  • Whether the weals presence corresponds to the time of day, work and recreation, menstrual cycle, holidays and travel overseas
  • Effect of food or drugs on the urticaria (NSAIDs, ACE-Inhibitors)
  • Association with infections or psychosocial stress
  • Any history of allergies or systemic illness
  • Occupational history, hobbies and activities
  • Previous treatment and response
  • Diagnostic procedures and result [1].
Figure 2. Diagnostic algorithm for chronic urticaria

Notes on diagnostic algorithm for chronic urticaria

open
Accordion: Urticaria

In some rare cases, recurrent angioedema is neither mast cell mediator-mediated nor bradykinin-mediated, and the underlying pathomechanisms remain unknown. These rare cases are referred to as "idiopathic angioedema" by some authors.

The consensus recommendations for diagnostic testing and management of chronic inducible urticaria can be used to identify the subtype of chronic inducible urticaria and to assess disease activity [1,6].

Provocation testing is used to determine the relevant trigger(s) and assess trigger thresholds. Provocation testing in positive patients usually results in the development of urticaria within a few minutes. One exception is delayed pressure urticaria, where it may be necessary to wait several hours for a response [6].

In patients with negative provocation responses, where chronic inducible urticaria is strongly suspected from the patient’s history, the test should be repeated. Ideally, the test should be conducted on a skin site that has previously been affected, although testing should not be done if weals have occurred in this site within the previous three days [6].

The results of provocation tests can be affected by medication. Therefore symptomatic treatment should be ceased before testing if possible. Antihistamines should be stopped three days before testing, and systemic glucocorticoids seven days before testing [6].

A sample form for the documentation of provocation testing is shown in Figure 2 [6].

 Figure 3. Provocation tests for chronic inducible urticaria

What is the differential diagnosis for chronic inducible urticaria?

The differential diagnosis depends on the specific type of chronic inducible urticaria and includes other forms of inducible and spontaneous urticaria, which may co-exist [8].

Assessment of disease activity and control

In addition to diagnosis, trigger threshold measurements are also used during treatment to measure ongoing disease activity and response to treatment [1,6].

The Urticaria Control Test (UCT) [9] is useful in the assessment of patients’ disease status and is validated to determine the level of disease control in both chronic spontaneous urticaria and chronic inducible urticaria [1]. The UCT has only four items with a clear cut-off for ‘well controlled’ vs ‘poorly controlled’ disease, making it useful in routine clinical practice.

The Angioedema Activity Score (AAS) allows the patient to score each of the five key factors relating to their symptoms from 0 to 3 (giving a daily score of 0–15) [10]. Daily AAS can be summed to give 7-day scores (AAS7), 4-week scores (AAS28), and 12-week scores (AAS84) [10].

Quality of life

Validated instruments can be used to assess the emotional impact of chronic urticaria and the effect on the patient’s quality of life (QOL), such as the Chronic Urticaria QOL questionnaire (CU-Q2oL) [11] and the Angioedema QOL questionnaire (AE-QOL) [1,12].

What is the treatment for chronic inducible urticaria?

Treatment aims to control symptoms [1,2].

The approach to the management of chronic inducible urticaria can involve:

  • Avoidance of trigger factors
  • Induction of tolerance
  • Pharmacological treatment to prevent mast cell mediator release or to prevent the effects of mast cell mediators [1].

Avoidance of trigger factors

It is often difficult for patients with chronic inducible urticaria to completely avoid the physical stimuli that trigger wealing [1]. Patients are recommended to minimise exposure to the trigger as much as possible, although induction of tolerance (described below) requires daily exposure to the trigger.

Inducing tolerance

Inducing tolerance can be useful in cold urticaria, cholinergic urticaria and solar urticaria. Tolerance induction lasts only a few days, and consistent daily exposure is required to maintain tolerance [1].

Pharmacological treatment of chronic urticaria

An algorithm to treat chronic urticaria is included in the international guidelines (see Figure 4) [1], which should be used with caution in children and pregnant/lactating women. Drugs that are contraindicated in pregnancy should not be used [1].

Treatment should be continued as required until the urticaria has cleared up.

Figure 4. Pharmacological treatment algorithm

Antihistamines

Some forms of chronic inducible urticaria are mediated by histamine. Intermittent or continuous treatment with H1-antihistamines is supported by clinical trial data [1,2].

Non-sedating antihistamines are preferred to older antihistamines, which have anticholinergic effects and sedative actions [1]. First line symptomatic treatment for chronic inducible urticaria include:

  • Cetirizine
  • Loratadine
  • Fexofenadine
  • Desloratadine
  • Levocetirizine
  • Rupatadine
  • Bilastine.

Terfenadine and astemizole are no longer available in New Zealand or Australia because they are cardiotoxic in combination with ketoconazole or erythromycin [1].

If standard doses are not effective, the doses of bilastine, loratadine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine and rupatadine can be increased up to four-fold (note that some of these agents are not available and the higher doses are not licensed in New Zealand or Australia) [1].

Most patients with chronic inducible urticaria who do not respond to standard doses of antihistamines will benefit from up-dosing, but they are not always effective [1]. Localised heat urticaria, aquagenic urticaria, and vibratory urticaria rarely respond to antihistamines.

Treatment of refractory chronic inducible urticaria

About one-third of patients continue to have symptoms despite maximal tolerated daily doses of antihistamine [3]. Patients with refractory chronic inducible urticaria should be referred to a dermatologist, immunologist or medical allergy specialist [1].

Omalizumab

Omalizumab has been reported to be effective in chronic inducible urticaria [1], including cholinergic urticaria [13], cold urticaria [14,15], solar urticaria [16], heat urticaria [17], symptomatic dermographism [18,19] and delayed pressure urticaria [20].

Note: Omalizumab is not indicated for the treatment of patients with chronic inducible urticaria in New Zealand or Australia.

Ciclosporin

No published trials have specifically investigated the use of ciclosporin in patients with chronic inducible urticaria, although a case-series (n=100) investigating its use in the management of chronic spontaneous urticaria included patients that also had chronic inducible urticaria (45% of cases). Control was achieved with ciclosporin or omalizumab in some cases refractory to antihistamines [21].

Note: Ciclosporin is not indicated for the treatment of patients with chronic inducible urticaria in New Zealand or Australia.

Corticosteroids

  • Systemic corticosteroids have not been studied in randomised controlled trials, and evidence for their use in chronic inducible urticaria is limited [1,2].
  • Long-term use of systemic corticosteroids should be avoided as high doses are often required to reduce the symptoms of urticaria with associated potentially serious adverse effects [1,2].
  • A short course of corticosteroids may be considered in cases of severe exacerbations of chronic inducible urticaria, but this is not always effective [1,2].

Phototherapy

Phototherapy has been successful in the treatment of patients with chronic inducible urticaria, particularly in patients with dermographism [1]. The most common form of phototherapy used is narrowband ultraviolet (UV)-B [8].

Other treatments

There is little evidence to support any other treatments for chronic inducible urticaria.

Immunomodulatory treatments may be of value to individual patients in particular clinical situations (eg, dapsone for cold urticaria) [8].

What is the outcome for chronic inducible urticaria?

Chronic inducible urticaria may resolve with treatment of symptoms and avoidance of the physical stimuli that triggers the urticaria. However, in many patients, the threshold for the relevant physical trigger is low and total avoidance of symptoms is almost impossible [1].

Self-skin examination
New smartphone apps to check your skin
Learn more
(Sponsored content)

 

Related information

 

References

  1. Zuberbier T, Aberer W, Asero R, et al. The EAACI/GA²LEN/EDF/WAO Guideline for the Definition, Classification, Diagnosis and Management of Urticaria. The 2017 Revision and Update. Allergy 2018; 73: 1393–1414. doi: 10.1111/all.13397. PubMed
  2. Australasian Society of Clinical Immunology and Allergy (ASCIA) CSU Working Party. Chronic Spontaneous Urticaria (CSU) Guideline. 2015. Available at: https://allergy.org.au/images/stories/pospapers/ASCIA_Guidelines_Chronic_Urticaria_2015.pdf [accessed 15/5/2018].
  3. Borlu M, Levent Cinar S, Kartal D (May 31st 2017). Chronic Inducible Urticaria Part I in Urticaria and Angioedema. Selda Pelin Kartal and Zekayi Kutlubay, IntechOpen, DOI: 10.5772/68069. Available at: https://www.researchgate.net/publication/317323701_Chronic_Inducible_Urticaria_Part_I. [accessed 10/12/2018]
  4. Maurer M, Weller K, Bindslev-Jensen C, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA2LEN task force report. Allergy 2011; 66: 317–30. PubMed
  5. Kaplan AP. Chronic urticaria and angioedema. N Engl J Med 2002; 346: 175–9. PubMed 
  6. Magerl M, Altrichter S, Borzova E, et al. The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA2LEN/EDF/UNEV consensus recommendations 2016 update and revision. Allergy 2016; 71: 780–802. doi: 10.1111/all.12884. PubMed
  7. Maurer M, Abuzakouk M, Berard F, et al. The burden of chronic spontaneous urticaria is substantial: Real-world evidence from ASSURE-CSU. Allergy 2017; 72: 2005–2016. PubMed
  8. Dice JP, Gonzalez-Reyes. Physical (inducible) forms of urticaria. Saini S, Elmets CA Eds. UpToDate. Waltham, MA: UpToDate [accessed 26 November 2018].
  9. Weller K, Groffik A, Church MK, et al. Development and validation of the Urticaria Control Test: a patient-reported outcome instrument for assessing urticaria control. J Allergy Clin Immunol 2014; 133(5): 1365–72, 1372.e1-6. doi:10.1016/j.jaci.2013.12.1076. PubMed
  10. Weller KG, M. Magerl, M. Tohme, et al. Development, validation and initial results of the Angioedema Activity Score. Allergy 2013; 68(9): 1185–92. PubMed
  11. Baiardini I, Pasquali M, Braido F, et al. A new tool to evaluate the impact of chronic urticaria on quality of life: chronic urticaria quality of life questionnaire (CU-QoL). Allergy 2005; 60(8): 1073–8. PubMed
  12. Weller K, Groffik A, Magerl M, et al. Development and construct validation of the angioedema quality of life questionnaire. Allergy 2012; 67: 1289–98. doi: 10.1111/all.12007. PubMed
  13. Metz M, Bergmann P, Zuberbier T, Maurer M. Successful treatment of cholinergic urticaria with anti-immunoglobulin E therapy. Allergy 2008; 63: 247–9. PubMed
  14. Metz M, Schutz A, Weller K, et al. Omalizumab is effective in cold urticaria-results of a randomized placebo-controlled trial. J Allergy Clin Immunol 2017; 140: 864–867. PubMed
  15. Boyce JA. Successful treatment of cold-induced urticaria/anaphylaxis with anti-IgE. J Allergy Clin Immunol 2006; 117: 1415–8. PubMed
  16. Guzelbey O, Ardelean E, Magerl M, Zuberbier T, Maurer M, Metz M. Successful treatment of solar urticaria with anti-immunoglobulin E therapy. Allergy 2008; 63: 1563–5. PubMed
  17. Bullerkotte U, Wieczorek D, Kapp A, Wedi B. Effective treatment of refractory severe heat urticaria with omalizumab. Allergy 2010; 65: 931–2. PubMed
  18. Maurer M, Schutz A, Weller K, et al. Omalizumab is effective in symptomatic dermographism-results of a randomized placebo-controlled trial. J Allergy Clin Immunol 2017; 140; 3: 870–3. Journal
  19. Krause K, Ardelean E, Kessler B, et al. Antihistamine-resistant urticaria factitia successfully treated with anti-immunoglobulin E therapy. Allergy 2010; 65: 1494–5. PubMed
  20. Bindslev-Jensen C, Skov PS. Efficacy of omalizumab in delayed pressure urticaria: a case report. Allergy 2010; 65: 138–9. PubMed
  21. Marin-Cabanas I, Berbegal de Gracia L, de Leon-Marrero F, Hispan P, Silvestre JF. Management of chronic spontaneous urticaria in routine clinical practice following the EAACI/GA(2) LEN/EDF/WAO guidelines. Actas Dermo-Sifiliograficas 2017; 108: e27–e32.DOI: 10.1016/j.adengl.2017.03.014. Journal

On DermNet NZ

Other websites

Books about skin diseases

See the DermNet NZ bookstore.