eMedicine Specialties > Dermatology > Allergy & Immunology
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
Differential Diagnoses
Mastocytosis
Urticaria, Chronic
Other Problems to Be Considered
Systemic mastocytosis and urticaria pigmentosa are associated with a positive Darier sign.
Forms of false dermographism (misnomers, not associated with urticaria) include (1) white dermographism, which is a blanching response resulting from capillary vasoconstriction following skin stroking and is more pronounced in persons with atopy; (2) black dermographism, which is black or greenish discoloration of the skin after contact with certain metallic objects; and (3) yellow dermographism, which probably results from bile pigment deposits in the skin.
Workup
Laboratory Studies
- The results from hematological and biochemical screening tests are normal. In some patients, an increase in blood histamine levels is seen after experimental scratching.
Procedures
- The diagnosis is usually made by observing the clinical response after using moderate pressure to stroke or gently scratch the skin. The site is important because areas protected from regular pressure and environmental influences, such as the back, are more reactive than more exposed areas, such as the buttocks and limbs.
- A dermographometer (spring-loaded stylus) can be used to apply graded, reproducible pressure (eg, 3600 g/cm2) and record skin responses. It is mostly limited to research settings.
Histologic Findings
- Biopsy specimens show dermal edema with a few perivascular mononuclear cells.
Treatment
Medical Care
Patients with simple dermographism are asymptomatic and require no therapy.
Recognition of the problem, avoidance of precipitating physical stimuli, reduction of stress and anxiety are important factors in medical care. Also, scratching because of dry skin can be reduced with good skin care and emollients.
H1 antihistamines are the drugs of choice. In some patients, several antihistamines or a combination of two may be required. Sedating antihistamines such as hydroxyzine can be helpful. Regular treatment may need to be continued for several months.
The addition of H2-receptor antagonists appears to result in little symptomatic benefit, although some studies have shown a further small reduction in the whealing response.10
Physical urticarias are usually unresponsive to systemic corticosteroids.
Narrowband UV-B phototherapy and oral psoralen plus UV-A light therapy have both been used as treatments for symptomatic dermographism. Subjective relief of pruritus and whealing and objective reduction of wheals are apparent.11 However, improvement is short-lived, and most patients relapse within 2-3 months of completing phototherapy.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antihistamines
Act by competitive inhibition of histamine at the H1 receptor, H2 receptor, or both. This mediates wheal and flare reactions, bronchial constriction, mucus secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.
Cetirizine (Zyrtec, Zyrtec Chewable Tablets)
Forms complex with histamine for H1-receptor sites in blood vessels, GI tract, and respiratory tract.
Dosing
Adult
10 mg PO qd
Pediatric
<2 years: Not recommended
2-6 years: 5 mg PO qd or 2.5 mg PO bid
>6 years: Administer as in adults
Interactions
Increases toxicity of CNS depressants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Sedation and antimuscarinic effects (low); caution in hepatic or renal dysfunction; doses >10 mg/d may cause drowsiness
Loratadine (Claritin)
Selectively inhibits peripheral histamine H1 receptors.
Dosing
Adult
10 mg PO qd
Pediatric
<2 years: Not recommended
2-12 years and <30 kg: 5 mg PO qd
>30 kg: Administer as in adults
Interactions
Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Initiate therapy at lower dose in liver impairment
Desloratadine (Clarinex)
Long-acting tricyclic histamine antagonist selective for H1 receptor. Relieves nasal congestion and systemic effects of seasonal allergy. Major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine.
Dosing
Adult
5 mg PO qd
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
Data are limited; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse effects, including QTc, observed
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose in hepatic impairment; rarely causes pharyngitis or dry mouth
Acrivastine (Semprex)
Competes with histamine for H1 receptors on GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions.
Dosing
Adult
8 mg PO tid
Pediatric
Not established
Interactions
Guanethidine, methyldopa, reserpine, or beta-blockers may decrease effects; CNS depressants, alcohol, and sympathomimetics increase toxicity
Contraindications
Documented hypersensitivity; within 14 d of initiating MAOI therapy; severe coronary disease; severe hypertension; elderly
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Sedation and antimuscarinic effects may occur; caution in high blood pressure, diabetes, ischemic heart disease, GI or GU obstruction, thyroid disease, prostatic hypertrophy, and increased intraocular pressure
Fexofenadine (Allegra)
Competes with histamine for H1 receptors on GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Does not sedate.
Dosing
Adult
60 mg PO bid
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Interactions
Toxicity increases with coadministration of erythromycin and ketoconazole
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
No data available on use while breastfeeding; may cause dizziness
Hydroxyzine (Atarax, Vistaril, Vistazine)
Sedative antihistamine that is also anxiolytic. Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS.
Dosing
Adult
Pruritus: 25 mg PO hs initially; increase prn to 25 mg PO tid/qid
Anxiety: 50-100 mg PO qid
Pediatric
<6 months: Not recommended
6 months to 6 years: 5-15 mg/d PO; increase to 50 mg/d PO divided tid/qid
>6 years: 15-25 mg/d PO; increase to 50-100 mg/d PO divided tid/qid
Interactions
May enhance response to alcohol, barbiturates, and other CNS depressants
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Associated with clinical exacerbations of porphyria (may not be safe for porphyria patients); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness
Follow-up
Further Outpatient Care
- Treat symptomatic dermographism until the problem is adequately controlled or resolved.
Prognosis
- The natural history of symptomatic dermographism is unpredictable. It may last for months or years, or be present intermittently. In many patients, the condition gradually improves and clears after several years. Symptomatic dermographism appears to have the best prognosis of the chronic urticarias in terms of clearance after 5 years (36%) and 10 years (51%) years.12
Patient Education
- Reassure patients about the benign nature of the disorder, and inform them of the possible prolonged course.
- Explain the adverse effects of antihistamines.
- For excellent patient education resources, visit eMedicine's Allergy Center and Skin, Hair, and Nails Center. Also, see eMedicine's patient education article Hives and Angioedema.
Miscellaneous
Medicolegal Pitfalls
- Dermographism can be distressing but is not life threatening. Warn patients undergoing treatment with antihistamines about drowsiness, especially when driving or handling machinery.
References
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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].
Lambiris A, Greaves MW. Dyspareunia and vulvodynia: unrecognised manifestations of symptomatic dermographism. Lancet. Jan 4 1997;349(9044):28. [Medline].
Matthews CN, Warin RP. Cold urticaria and cold precipitated dermographism. Br J Dermatol. Jan 1970;82:91. [Medline].
Jedele KB, Michels VV. Familial dermographism. Am J Med Genet. May 1 1991;39(2):201-3. [Medline].
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].
Taskapan O, Harmanyeri Y. Evaluation of patients with symptomatic dermographism. J Eur Acad Dermatol Venereol. Jan 2006;20(1):58-62. [Medline].
Wallengren J, Isaksson A. Urticarial Dermographism: Clinical features and response to psychosocial stress. Acta Derm Venereol. 2007;87:493-8. [Medline].
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].
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].
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].
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Champion RH. Urticaria: then and now. Br J Dermatol. Oct 1988;119(4):427-36. [Medline].
Giam YC, Rajan VS. An approach to urticaria. Ann Acad Med Singapore. Jan 1983;12(1):74-80. [Medline].
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.
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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].
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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
Contributor Information and Disclosures
Author
Simone Laube, MD, MRCP, Consulting Staff, Department of Dermatology, Aberdeen Royal Infirmary, UK
Simone Laube, MD, MRCP is a member of the following medical societies: British Association of Dermatologists
Disclosure: Nothing to disclose.
Medical Editor
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.
Pharmacy Editor
Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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.
Managing Editor
Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
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.
CME Editor
Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.
Chief Editor
William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other