Dermographism Urticaria Clinical Presentation

  • Author: Simone Laube, MD, MRCP; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Aug 5, 2011
 

History

Whealing usually develops within 5-10 minutes of stroking the skin and persists for 15-30 minutes. A short refractory period after clearance of the wheal has been reported. Giant wheals can develop if deep extension of the swelling occurs.

  • Intermediate and delayed forms of dermographism are also described. These develop more slowly and can last several hours to days.
  • In patients with symptomatic dermographism, the skin eruption is associated with itching, which is often most severe at night.
  • Symptoms can be aggravated by heat (hot bath), minor pressure (scratching, friction from clothes or from rubbing with towels), exercise, stress, and emotion.
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Physical

Itching and whealing can affect all body surfaces, but the scalp and genitalia are less frequently involved. However, dyspareunia and vulvodynia have been reported in patients with symptomatic dermographism.[3] Rarer forms of dermographism include the following:

  • Red dermographism: Repeated rubbing induces small, punctate wheals that are more prominent on the trunk than on the limbs. This form is possibly associated with seborrheic dermatitis.
  • Follicular dermographism: Transitory, discrete, follicular, urticarial papules occur on a bright erythematous background.
  • Cholinergic dermographism: A large erythematous line studded with punctate wheals similar to cholinergic urticaria (wheals smaller than classic urticaria and surrounded by large areas of macular erythema). Purpura has been noted in severe cases. It can be associated with cholinergic urticaria.
  • Delayed dermographism: Approximately 3-8 hours after the immediate dermographic response, a deep, tender, burning wheal returns to the same site and persists for up to 48 hours. This form is recalcitrant to conventional therapy and is closely related to pressure urticaria.
  • Cold precipitated dermographism: One case report has been published.[4]
  • Exercise-induced dermographism
  • Familial dermographism: One case report has been published. It is probably inherited as an autosomal dominant trait.[5]
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Causes

Symptomatic dermographism is usually idiopathic. It may have an immunologic basis in some patients. Passive transfer of the dermographic response with immunoglobulin E– or immunoglobulin M–containing serum has been reported but no allergen has been identified.

  • Symptomatic dermographism may be triggered by drugs (eg, penicillin), an insect bite, Helicobacter pylori infection, or an infestation (eg, scabies, Fasciola hepatica).
  • Congenital symptomatic dermographism has been described as the first sign of systemic mastocytosis.[6]
  • Approximately 75% of patients with hypereosinophilic syndrome, which has multisystem involvement and high mortality, have dermographism.
  • Psychologic factors and a history of stressful life events have been implicated as triggering factors in 30% of patients.[7] However, a small prospective study showed no alteration in dermographic reaction following social stress provocation tests.[8]
  • One case report describes symptomatic dermographism secondary to trauma from a coral reef.[9]
  • Symptomatic dermographism may be a presenting feature of dermatomyositis.[10]
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Contributor Information and Disclosures
Author

Simone Laube, MD, MRCP  Consulting Staff, Department of Dermatology, Borders General Hospital, Melrose and Western General Hospital

Simone Laube, MD, MRCP is a member of the following medical societies: British Association of Dermatologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Shyam Verma, MBBS, DVD, FAAD  Adjunct Clinical Assistant Professor, Department of Dermatology, University of Virginia, State University of New York at Stonybrook, Penn State University

Shyam Verma, MBBS, DVD, FAAD is a member of the following medical societies: American Academy of Dermatology

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.

Paul Krusinski, MD  Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

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.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Elsbeth Young, MD, FRCP, to the development and writing of this article.

References

  1. Dinc A, Karaayvaz M, Caliskaner AZ, Pay S, Erdem H, Turan M. Dermographism and atopy in patients with Behcet's disease. J Investig Allergol Clin Immunol. Nov-Dec 2000;10(6):368-71. [Medline].

  2. Martorell A, Sanz J, Ortiz M, Julve N, Cerda JC, Ferriols E. Prevalence of dermographism in children. J Investig Allergol Clin Immunol. May-Jun 2000;10(3):166-9. [Medline].

  3. Lambiris A, Greaves MW. Dyspareunia and vulvodynia: unrecognised manifestations of symptomatic dermographism. Lancet. Jan 4 1997;349(9044):28. [Medline].

  4. Matthews CN, Warin RP. Cold urticaria and cold precipitated dermographism. Br J Dermatol. Jan 1970;82:91. [Medline].

  5. Jedele KB, Michels VV. Familial dermographism. Am J Med Genet. May 1 1991;39(2):201-3. [Medline].

  6. Grimm V, Mempel M, Ring J, Abeck D. Congenital symptomatic dermographism as the first symptom of mastocytosis. Br J Dermatol. Nov 2000;143(5):1109. [Medline].

  7. Taskapan O, Harmanyeri Y. Evaluation of patients with symptomatic dermographism. J Eur Acad Dermatol Venereol. Jan 2006;20(1):58-62. [Medline].

  8. Wallengren J, Isaksson A. Urticarial Dermographism: Clinical features and response to psychosocial stress. Acta Derm Venereol. 2007;87:493-8. [Medline].

  9. Wu JJ, Huang DB, Murase JE, Weinstein GD. Dermographism secondary to trauma from a coral reef. J Eur Acad Dermatol Venereol. Nov 2006;20:1337-8. [Medline].

  10. Rahim KF, Dawe RS. Dermatomyositis presenting with symptomatic dermographism and raised troponin T: a case report. Journal of Medical Case Reports. July 2009;3:7319. [Medline]. [Full Text].

  11. Sharpe GR, Shuster S. In dermographic urticaria H2 receptor antagonists have a small but therapeutically irrelevant additional effect compared with H1 antagonists alone. Br J Dermatol. Nov 1993;129(5):575-9. [Medline].

  12. Borzova E, Rutherford A, Konstantinou GN, Leslie KS, Grattan CE. Narrowband ultraviolet B phototherapy is beneficial in antihistamine-resistant symptomatic dermographism: A pilot study. J Am Acad Dermatol. Sept 2008;59:752-7. [Medline].

  13. Metz M, Altrichter S, Ardelean E, at al. Anti-Immunoglobulin E Treatment of Patients with Recalcitrant Physical Urticaria. Int Arch Allergy Immunol. 2011;154:177-180. [Medline].

  14. van der Valk PG, Moret G, Kiemeney LA. The natural history of chronic urticaria and angioedema in patients visiting a tertiary referral centre. Br J Dermatol. Jan 2002;146(1):110-3. [Medline].

  15. Casale TB, Sampson HA, Hanifin J, et al. Guide to physical urticarias. J Allergy Clin Immunol. Nov 1988;82(5 Pt 1):758-63. [Medline].

  16. Champion RH. Urticaria: then and now. Br J Dermatol. Oct 1988;119(4):427-36. [Medline].

  17. Giam YC, Rajan VS. An approach to urticaria. Ann Acad Med Singapore. Jan 1983;12(1):74-80. [Medline].

  18. Grattan CEH, Kobza Black A. Urticaria and mastocytosis. In: Burns DA, Breathnach SM, Cox N, Griffiths C, eds. Rook's Textbook of Dermatology. Vol 3. 7th ed. London, England: Blackwell Science; 2004:47.1-47.37.

  19. Jorizzo JL, Smith EB. The physical urticarias. An update and review. Arch Dermatol. Mar 1982;118(3):194-201. [Medline].

  20. Kirby JD, Matthews CN, James J, Duncan EH, Warin RP. The incidence and other aspects of factitious wealing (dermographism). Br J Dermatol. Oct 1971;85(4):331-5. [Medline].

  21. Kobza Black A. The physical urticarias. In: Champion RH, Greaves MW, Kobza Black A, Pye RJ, eds. The Urticarias. Edinburgh, Scotland: Churchill Livingstone; 1985:168-90.

  22. Nettis E, Pannofino A, D'Aprile C, Ferrannini A, Tursi A. Clinical and aetiological aspects in urticaria and angio-oedema. Br J Dermatol. Mar 2003;148(3):501-6. [Medline].

  23. Wong RC, Fairley JA, Ellis CN. Dermographism: a review. J Am Acad Dermatol. Oct 1984;11(4 Pt 1):643-52. [Medline].

 
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