Physical Urticarias

What is urticaria?

Urticaria (sometimes called hives) is an itchy rash caused by tiny amounts of fluid that leak from blood vessels just under the skin surface. Urticaria is classed as:

• Acute urticaria - if it develops suddenly and lasts less than six weeks. Most cases last less than 48 hours. It can affect anyone at any age. Some people have recurring episodes of acute urticaria. Physical urticaria (described below) is one cause of recurring episodes of acute urticaria.
• Chronic urticaria - if the rash persists longer than six weeks. (Chronic means persistent or ongoing.) This is uncommon. In most cases the cause is not known.

What does the rash of acute urticaria look like?

The rash usually appears suddenly and can affect any area of skin. Small raised areas called weals develop on the skin. The weals look like mild blisters and they are itchy. Each weal is white or red and is usually surrounded by a small red area of skin which is called a flare. The 'weal and flare' rash of urticaria looks similar to the rash caused by a nettle sting.

The weals are commonly 1-2 cm across but can vary in size. For example, in cholinergic urticaria (described below) they are much smaller. There may be just a few weals but sometimes many develop on the skin. Sometimes weals that are next to each other join together to form larger ones. The weals can be any shape but are often circular. As a weal fades, the surrounding flare remains for a while. This makes the affected area of skin look blotchy and red. The blotches then fade gradually and the skin returns to normal. Each weal usually lasts less than 24 hours.

What causes acute urticaria?

A 'trigger' causes cells in the skin to release chemicals such as histamine. The chemicals cause fluid to leak from tiny blood vessels under the skin surface. The fluid pools to form weals. The chemicals also cause the blood vessels to open wide (dilate) which causes the flare around the weals. The trigger is not identified in about half of cases. Some known triggers include:

• Physical urticaria. This is when a rash appears when the the skin is physically stimulated.
• Allergies - for example:
  • Food allergies such as allergies to nuts, strawberries, citrus fruit, egg, food additives, spices, chocolate, or shellfish. Sometimes you can develop an allergy to a food even if you have eaten it without any problem many times before.
  • Allergies to insect bites and stings.
  • Allergies to medicines such as penicillin, aspirin, anti-inflammatory painkillers, etc.
• A viral infection such as a cold or 'flu can trigger an urticarial rash in some people. (You 'react' to the virus.) A mild viral infection which causes few other symptoms is probably a common trigger of an urticarial rash that develops without an apparent cause.
• Skin contact with 'sensitizers' causes a local area of 'contact urticaria' in some people. For example, chemicals, latex, cosmetics, plants, ointments, nettle stings, etc.

The rest of this leaflet deals only with physical urticaria. There are separate leaflets called 'Acute Urticaria' (for a general overview about all types of acute urticaria), and 'Chronic Urticaria'.

Different types of physical urticaria

There are different types of physical urticaria. The reason why a rash appears in affected people is not clear. The physical stimulus somehow causes a release of histamine and other chemicals which causes the rash. The main types of physical urticaria include the following.

Dermographism

Dermographism means 'skin writing'. People with this condition develop the rash on areas of skin that have been firmly stroked. (Because of this, you could 'write' on someones skin by applying firm pressure with a finger or other object. The rash follows the line of the 'writing' on the skin.) The affected area of skin is usually very itchy, but in some mild cases it does not itch much. Although any part of the skin can be affected, the palms, soles of the feet, genital skin and scalp are less commonly affected. Dermographism is more prone to occur when you are hot. For example, it may develop more easily when you rub yourself firmly with a towel after a hot shower. The rash tends to last less than an hour. In many cases the pressure needed to be applied to cause the rash is quite firm. However, some people develop dermographism with just light pressure.

Up to 1 in 20 people will develop dermographism at some stage of life. It most commonly first develops in early adult life. In most cases, the condition tends to improve gradually over a few years and it goes or becomes less severe. However, in some cases the condition remains troublesome for many years.

Cholinergic urticaria

Cholinergic urticaria is quite common. It is caused by sweating and is sometimes called heat bumps. The urticarial rash is quite distinct as the weals are very small (2-3 mm) with a red flare around each one. The rash appears within a few minutes of sweating and tends to be worst on the chest, back and arms. The rash lasts from 30 minutes to an hour or more before fading away. Some people become slightly wheezy and short of breath for the duration of the rash.

The sweating that triggers the rash may be due to exercise, heat, fever, emotion or eating spicy food. It can be a real nuisance when trying to exercise. In severe cases, hundreds of tiny weals develop when you run or do other types of exercise. Sometimes the tiny weals join together to form larger ones. Cholinergic urticaria most commonly first develops in early adult life. In many cases the condition tends to improve after a few years and it goes or becomes less severe. However, in some cases the condition remains troublesome for many years.

Cold urticaria

Cold urticaria is a relatively uncommon. An urticarial rash develops after being exposed to cold, including rain, cold winds and cold water. It may be the cold that triggers the rash, or the re-warming of the skin after coming in from the cold. The rash affects the chilled parts of the skin. If a large area of skin has been chilled, the rash can be very extensive. For example, swimming in cold water may cause a widespread and severe rash over most of the body that can make you dizzy and faint. (For this reason, if you are known to develop cold urticaria, you should never go swimming alone.)

Delayed pressure urticaria

Delayed pressure urticaria is uncommon. It can develop alone but it commonly affects people who also have chronic urticaria (see separate leaflet called 'Urticaria - Chronic'). In this type of urticaria the rash develops 4-6 hours after the affected area of skin has had deep prolonged pressure applied. For example, after wearing a tight seat belt, or wearing a tight watch strap, or after gripping a tool such as a screwdriver for a reasonable period of time. The rash can be painful and tends to last several hours, or even a day or so.

Solar urticaria

This is rare. In this condition an urticarial rash develops on skin exposed to sunlight.

Aquagenic (water contact) urticaria

In this rare condition an urticarial rash develops on skin exposed to water of any temperature.

What is the treatment for physical urticarias?

Once you know what causes the rash, it may be possible to avoid situations that trigger it. For example, dermographism can often be prevented by avoiding firm pressure against the skin as much as possible. In mild cases, no additional treatment may be needed.

Antihistamines

Many of the physical urticarias are helped by taking antihistamine medicines. (However, antihistamines may not help some cases of delayed pressure urticaria.) Antihistamines block the action of histamine which is involved in causing urticaria.

You can get antihistamines on prescription. You can also buy them from pharmacies. There are several brands. The pharmacist will advise.

• Modern brands usually work well and are unlikely to cause side-effects. They sometimes cause drowsiness - particularly if you drink alcohol.
• Older brands will often make you drowsy - but this effect may be welcome at bedtime if itch is troublesome.

Some people take antihistamines 'now and then' when a rash flares up. If you take an antihistamine as soon as the rash appears, the rash tends to fade quicker than it would do normally. If the rash recurs frequently, then your doctor may advise a regular dose of an antihistamine to prevent the rash from occuring. If you have cholinergic urticaria and know that you get a rash on exercise, a dose of an antihistamine just before you do exercise may help to prevent or limit a flare up of the rash.

Steroid tablets

Sometimes a short course of steroids will help if the symptoms of delayed urticaria are severe and not helped by antihistamines.

What is the outlook (prognosis)?

Physical urticarias most commonly occur in healthy young adults. You can have two or more different types of urticaria at the same time. As a rule, physical urticarias tend to improve and become less troublesome with time (often going, or being much less troublesome after 2-5 years).

However, it is not possible to predict for an individual how long the problem will last and in some cases the condition lasts many years. In many cases, by avoiding the trigger and/or by taking antihistamines, the condition can be controlled.

For a list of websites that contain pictures of skin conditions including urticaria see www.patient.co.uk/showdoc/1097/