Contact Urticaria Syndrome Clinical Presentation

  • Author: Saqib Bashir, MB, ChB, MD, MRCP; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 11, 2012
 

History

  • Many agents are capable of causing contact urticaria syndrome; therefore, a detailed history is essential in establishing the etiology.
    • Contact urticaria reactions appear within minutes to approximately 1 hour after exposure of the urticariant to the skin.
    • The patient may report a local burning sensation, tingling, or itching. Swelling and redness may be seen (wheal and flare).
    • The patient may be able to associate the symptoms to exposure to a specific substance. In some cases, this exposure may include the application of cosmetic products, especially to the face (cosmetic intolerance syndrome).
    • Details of the patient's employment provide insight into possible causes in the workplace, especially if the symptoms are temporally related to work.
    • The patient may be able to identify what he or she was doing at the onset of symptoms, again allowing the physician to narrow down the possible causes.
    • The extent of extracutaneous involvement (eg, asthma, rhinitis, conjunctivitis, gastrointestinal upset) should be ascertained.
    • A history of previous anaphylaxis should be sought, as should a personal or family history of atopy.
  • A staging system of contact urticaria syndrome has been described by Amin and Maibach.[16]
    • Cutaneous reaction only (stages 1 and 2)
      • Stage 1 - Localized urticaria (redness and swelling); dermatitis (eczema); nonspecific symptoms (eg, itching, tingling, burning sensation)
      • Stage 2 - Generalized urticaria
    • Extracutaneous reactions (stages 3 and 4)
      • Stage 3 - Bronchial asthma (wheezing); rhinitis, conjunctivitis (eg, runny nose, watery eyes); orolaryngeal symptoms (eg, lip swelling, hoarseness, difficulty in swallowing); gastrointestinal symptoms (eg, nausea, vomiting, diarrhea, cramps)
      • Stage 4 - Anaphylactoid reactions (shock)
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Physical

Signs upon physical examination may be variable depending on when the patient presents to the clinic. At one extreme, the patient may be asymptomatic, while at the other extreme, the patient may have a generalized urticaria with extracutaneous symptoms.[17]

  • Skin findings
    • Localized or generalized wheals may be present, especially on the hands, or eczematous skin may be observed if contact urticaria syndrome has progressed to or developed in association with an eczematous dermatitis.
    • By definition, contact urticaria syndrome lesions disappear within 24 hours of onset. Therefore, the skin may appear healthy, depending on when the patient presents to the physician.
    • An ordinal scale to score erythema is as follows[18] :
      • Slight erythema, either spotty or diffuse - 1+
      • Moderate uniform erythema - 2+
      • Intense redness - 3+
      • Fiery redness with edema - 4+
    • An ordinal scale to score edema is as follows[19] :
      • Slight edema, barely visible or palpable - 1
      • Unmistakable wheal, easily palpable - 2
      • Solid, tense wheal - 3
      • Tense wheal, extending beyond the test area - 4
  • Respiratory findings
    • The patient may be in varying degrees of respiratory distress if a respiratory component to the contact urticaria syndrome is involved.
    • Rhinitis may be present, and wheezing may be heard upon auscultation.
    • Results of the examination, however, may be normal if the disease is quiescent or if no extracutaneous expression is present.
  • Ocular findings: Conjunctivitis may be seen in active extracutaneous disease.
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Causes

  • Some of the more commonly reported causes of nonimmunologic contact urticaria include balsam of Peru, benzoic acid, cinnamic alcohol, cinnamic aldehyde, sorbic acid, and dimethylsulfoxide.[20] In some patients, nonimmunologic contact urticaria may account for cosmetic intolerance syndrome.
  • Reported causes of immunologic contact urticaria include natural rubber latex, raw meat and fish, semen, many antibiotics, some metals (eg, platinum, nickel), acrylic monomers, short-chain alcohols, benzoic and salicylic acids, parabens, polyethylene glycol, polysorbate, and other miscellaneous chemicals.[20, 21]
  • Food handlers, exposed to a variety of proteins, may develop immunologic contact urticaria or an eczematous reaction known as protein contact dermatitis on the hands and forearms. The 2 phenomena may overlap and may be different clinical appearances of the same IgE-mediated process. Also of note, the development of eczematous skin in food handlers is also likely to have an irritant component, which should be in the clinical differential. The list of triggers is long, but, conveniently, it has been categorized into the following 4 groups[22, 23] :
    • Group 1 - Fruits, vegetables, spices, plants, and woods
    • Group 2 - Animal proteins
    • Group 3 - Grains
    • Group 4 - Enzymes
  • Processionary pine caterpillars (Thaumetopoea pityocampa) have fine hairs that can become scattered and airborne, leading to exposure amongst forestry workers and recreational visitors to endemic areas, including children.[24] Affected personnel in one study included pinecone or resin collectors, woodcutters, farmers, and stockbreeders.[25] The mechanism is an immunologic contact urticaria, which can lead to severe reactions; in one cohort of 16 patients, 80% had angioedema and 14% had severe anaphylaxis. Wheals were seen primarily on the neck and forearms.[26]
  • Importantly, remember that the causative agent may be airborne, in the correct context (eg, in a manufacturing facility, plant/animal dander exposure).
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Contributor Information and Disclosures
Author

Saqib Bashir, MB, ChB, MD, MRCP  Consultant Dermatologist and Dermatological Surgeon, King's College Hospital, NHS Foundation Trust, UK; Research Fellow, Department of Dermatology, University of California, San Francisco, School of Medicine

Saqib Bashir, MB, ChB, MD, MRCP is a member of the following medical societies: British Association of Dermatologists, British Medical Association, Royal College of Physicians, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Howard I Maibach, MD  Professor and Vice Chairperson, Department of Dermatology, University of California School of Medicine at San Francisco; Consulting Staff, University of California Hospitals

Howard I Maibach, MD is a member of the following medical societies: American Academy of Dermatology, American College of Forensic Examiners, American College of Physicians, American Contact Dermatitis Society, American Dermatological Association, American Federation for Clinical Research, American Medical Association, California Medical Association, Pacific Dermatologic Association, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Donald Belsito, MD  Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Donald Belsito, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Dermatology Foundation, New York County Medical Society, New York Dermatological Society, Noah Worcester Dermatological Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Celgene Honoraria Safety Monitoring Committee

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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