Combined cold- and heat-induced cholinergic urticaria

Evidence for histamine release in chronic inducible urticaria – A systematic review

Background

Chronic inducible urticaria (CIndU) constitutes a group of nine different CIndUs in which pruritic wheals and/or angioedema occur after exposure to specific and definite triggers. Histamine released from activated and degranulating skin mast cells is held to play a key role in the pathogenesis of CIndU, but evidence to support this has, as of yet, not been reviewed systematically or in detail. We aim to characterize the role and relevance of histamine in CIndU.

Methods

We systematically searched 3 electronic databases (PubMed, Scopus, and Embase) for studies that reported increased serum or skin histamine concentration (direct evidence) or in vitro or ex vivo histamine release (indirect evidence) following trigger exposure.

Results

An initial total of 3,882 articles was narrowed down to 107 relevant studies of which 52 were in cold urticaria, 19 in cholinergic urticaria, 14 in heat urticaria, 10 in contact urticaria, 7 each in solar urticaria and vibratory angioedema, 4 each in symptomatic dermographism and aquagenic urticaria, and 3 in delayed pressure urticaria. The results of our review support that histamine has a key pathogenic role in the pathogenesis of all CIndUs, but it is not the sole mediator as evidenced by the often poor relationship between the level of histamine and severity of symptoms and the variable clinical efficacy of H1-antihistamines.

Conclusions

Histamine released from skin mast cells is a key driver of the development of signs and symptoms and a promising therapeutic target in CIndU.

Physical urticaria: prevalence, type and natural course in a tropical country

BACKGROUND

Physical urticarias (PU) are an urticarial response to different specific physical stimuli. PU can occur concurrently with chronic spontaneous urticaria or another type of PU.

OBJECTIVE

We aimed to study the prevalence, type, clinical data and natural course of each type of PU and other inducible urticarias and also the prognostic factors for remission of patients visiting a tertiary referral hospital.

METHOD

We performed a retrospective study of 1200 chronic urticaria patients who visited our Urticaria Clinic during a period of 5 years.

RESULTS

Of the 1200 chronic urticaria patients, 86 (7.2%) were diagnosed as PU and other inducible urticarias. The most common type of PU was symptomatic dermographism (n = 35, 40.7%) followed by cold urticaria (n = 20, 23.3%) and delayed pressure urticaria (n = 11, 12.8%), respectively. Twelve patients (13.9%) had associated chronic spontaneous urticaria. None of the cases had multiple types of PU. Erythrocyte sedimentary rate elevation was the most common abnormal laboratory result. Nevertheless, only 4.6% declared a related infection. For each type, the median time after onset before 50% remission showed that cholinergic urticaria took the shortest course (34 months) and delayed pressure urticaria took the longest period (110 months). After 1 year and 5 years from the onset of symptoms, 13% and 50% of PU patients were free of symptoms, respectively.

CONCLUSION

This study emphasized the variety of PU, other inducible urticarias and natural courses based on tertiary hospital care. PU and other inducible urticarias have tendency to have a longer course than chronic spontaneous urticaria.

Exercise-induced asthma and anaphylaxis

With increased popularity in exercise, the number of individuals with exercise-induced asthma (EIA), or 'exercise-induced bronchospasm', has increased due to an increased awareness among physicians of the clinical symptoms associated with EIA. EIA affects approximately 75 to 95% of asthmatic patients. 40% of children with allergic rhinitis have EIA, whereas only 3 to 11% of nonasthmatics have EIA. Although athletes with asthma have been recognised for years, EIA in nonasthmatic individuals has gained recognition since the 1984 Olympics. Vague symptoms of recurring poor performance, fatigue despite adequate conditioning, or 'getting winded' during an athlete's usual workout may be the presenting complaints. Athletes may be more likely to attribute these symptoms to poor conditioning or an upper respiratory infection, and not seek immediate assistance. Younger athletes may complain of stomach ache or refuse to participate in strenuous play because of an inability to keep up with other children. Additionally, an awareness of exercise-induced anaphylaxis needs to be considered when discussing aspects of airway compromise following exercise; however, its presentation is more urgent than those with EIA. Although the pathophysiology of EIA is somewhat controversial, the most likely explanation is a combination of heat and water loss leading to mediator release. The different medications that have been used to treat EIA are based on theories regarding the bronchial hyperreactivity of EIA.

Preventing, Diagnosing, and Treating Cold Urticaria

In brief While most cases of cold urticaria are mild and characterized only by pruritus, severe anaphylactic reaction is possible. Our patient, a healthy male runner, experienced intermittent and sometimes severe pruritus and severe urticaria after running in the cold. Avoiding cold air and cold water or using prophylactic medications that suppress the release of mast cell mediators has proved modestly successful in preventing and treating cold urticaria. Patients who develop cold urticaria often improve with time.

Refractory cholinergic urticaria successfully treated with ketotifen

Four patients with cholinergic urticaria associated with additional cardiorespiratory manifestations are described. Two patients reported cold, in addition to heat and exercise, as a factor inducing symptoms. Prospective exercise challenge documented a rise in in plasma histamine sixfold to 20-fold above baseline values that accompanied onset of symptoms. All four subjects had proved refractory to conventional antihistamine therapy. Institution of ketotifen at doses ranging from 3 to 8 mg per day resulted in symptomatic improvement, and in all four subjects a repeat exercise challenge confirmed clinical improvement. In three subjects exercise challenge with ketotifen demonstrated blockade of mast cell-mediator release. Plasma histamine levels remained at baseline. In the fourth patient, histamine rose to about half the peak observed before ketotifen therapy. These findings confirm the observation that ketotifen is both an H1 histamine-receptor antagonist as well as a stabilizer of mast cell-mediator release. We speculate that ketotifen may prove more effective than conventional antihistamines in the management of severe urticaria.

Combined cold urticaria and cholinergic urticaria--clinical characterization and laboratory findings

Thirteen patients with both cold and cholinergic urticaria are reported. There was considerable variability, particularly in the cold urticaria which was of the common cold contact type in seven patients, of the generalized cold induced cholinergic type in two and in four patients the lesions induced by direct contact with ice were morphologically like cholinergic urticaria, but appeared despite prior application of an acetyl choline antagonist. The natural history, laboratory findings and the effects of therapy are discussed.