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Urticaria, Dermographism
Updated: Feb 26, 2009
Introduction
Background
The term dermographism literally means writing on the skin. Firm stroking of the skin produces an initial red line (capillary dilatation), followed by an axon-reflex flare with broadening erythema (arteriolar dilatation) and the formation of a linear wheal (transudation of fluid/edema) termed the triple response of Lewis. An exaggerated response to this constitutional whealing tendency is seen in approximately 2-5% of the population and is termed dermographism. In a minority of people, it is accompanied by itching (symptomatic dermographism).
For information on other the types of urticaria not discussed in this article, see the following articles:
- Urticaria, Acute
- Urticaria, Cholinergic
- Urticaria, Chronic
- Urticaria, Contact Syndrome
- Urticaria, Pressure
- Urticaria, Solar
Pathophysiology
The exact mechanism of dermographism remains uncertain. Trauma may release an antigen that interacts with the membrane-bound immunoglobulin E of mast cells, which release inflammatory mediators, particularly histamine, into the tissues. This causes small blood vessels to leak, allowing fluid to accumulate in the skin. Other mediators possibly involved are leukotrienes, heparin, bradykinin, kallikrein, and peptides such as substance P.
Frequency
International
Dermographism is the most common of the physical urticarias and can occur with other forms of urticaria. Increased incidence has been reported in pregnancy (especially in second half), at the onset of menopause, in atopic children, and in patients with Behçet disease.1
Mortality/Morbidity
Simple dermographism is the most common variant, and patients with this form are asymptomatic. However, other forms are associated with pruritus, and this can significantly affect people's quality of life. Most people with dermographism are otherwise healthy. An association with thyroid disease has been described in some patients but remains controversial.
Race
No racial variance in prevalence is known.
Sex
Whether a sexual variance in prevalence occurs is unclear. None has been consistently reported, although one study on dermographism in children reported a female predominance.2
Age
Dermographism can appear in persons of any age but is more common in young adults. Peak incidence is in the second and third decades.
Clinical
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.
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
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
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References
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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].
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Further Reading
Keywords
dermatographism, urticaria, urticarial dermographism, factitious urticaria, allergy, allergic reaction, anaphylaxis, anaphylactoid reaction, angioedema, triple response of Lewis, linear wheal, whealing, red dermatographism, red urticaria, skin scratch reactions, hives, itching
