eMedicine Specialties > Dermatology > Allergy & Immunology

Urticaria, Pressure

Author: Joslyn S Kirby, MD, Assistant Professor, Department of Dermatology, Milton S Hershey Penn State Medical Center
Coauthor(s): Ellen J Kim, MD, Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania; Robin M Levin, MD, Staff Physician, Assistant Professor, Department of Family Medicine, Division of Dermatology, Kennedy Hospital at Stratford; Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Jul 23, 2009

Introduction

Background

Patients with urticaria for more than 6 weeks are given the diagnosis of chronic urticaria (CU). This distinction is important because an inciting event or etiology is not identified for the majority of patients with chronic urticaria, giving rise to the often-used term, chronic idiopathic urticaria (CIU). A proportion of patients with chronic urticaria have physical urticaria,1  which is urticaria incited by a physical stimulus such as cold, vibration, or pressure. Also see Urticaria, Cholinergic; Urticaria, Contact Syndrome; Urticaria, Dermographism; and Urticaria, Solar.

Pressure urticaria is an uncommon form of physical urticaria. Pressure urticaria may occur immediately (within minutes) after a pressure stimulus2 ; however, more commonly, pressure urticaria develops after a delay of 4-6 hours after a pressure stimulus; hence, the designation delayed pressure urticaria (DPU) is used. The wheals may last for 8-72 hours. The hands, feet, trunk, buttocks, legs, and face are the most common areas affected. Lesions can be induced by a variety of stimuli, including standing, walking, wearing of tight clothes, or sitting on a hard surface.3

Pathophysiology

The pathogenesis of delayed pressure urticaria is unknown. No allergen can usually be identified. Mast cells and histamine release are believed to play roles because the injection of compound 48/80, which causes depletion of mast cell mediators, prevents the induction of lesions in the injected area.4 Histamine levels are increased in lesional skin, and intracellular histamine levels are decreased in peripheral white blood cells.5 Despite these findings and the finding of increased stimulated histamine release, histamine is not likely to be the sole mediator in pressure urticaria, given the relative unresponsiveness of the condition to antihistamine treatment.

Other possible mediators include eosinophils, given the elevated numbers of eosinophils, eosinophil cationic protein (ECP), and eosinophil cationic factor (ECF) found in biopsy specimens from some patients with delayed pressure urticaria, particularly bullous delayed pressure urticaria.6 Elevated concentrations of interleukins 5 and 6 and leukotrienes have also been found in lesional skin of pressure urticaria patients.7,8

Frequency

United States

Delayed pressure urticaria is considered a rare entity. Some investigators suggest that delayed pressure urticaria is more prevalent but is not consistently recognized. One study of 2310 patients with urticaria, seen over 32 years, found the prevalence of delayed pressure urticaria to be 2%.9

Mortality/Morbidity

Depending on the severity of the disease and the associated symptoms, delayed pressure urticaria can be disabling, especially in patients who perform manual labor. Delayed pressure urticaria is a chronic disease, with a mean duration of 9 years (range, 1-40 y).10 The morbidity of delayed pressure urticaria varies, depending on the severity and the response to treatment.

Quality-of-life (QOL) tools have demonstrated an impairment in QOL scores similar to patients with cardiac disease or chronic dermatoses such as psoriasis and atopic eczema. QOL scores were lowest for energy, social isolation, emotional reaction, and sleep disturbance. The dimension of daily living activities was more profoundly impaired in patients with chronic idiopathic urticaria than in those with atopic eczema or psoriasis.11

Sex

Delayed pressure urticaria is slightly more common in men than in women.

Age

The peak age of onset of delayed pressure urticaria is in the 20s and 30s (range, 5-63 y).10

Clinical

History

  • Signs and symptoms of delayed pressure urticaria are atypical in comparison to most types of urticaria.
    • Onset is typically delayed, most commonly occurring 4-hours after the pressure stimulus. Less commonly, wheals due to pressure develop within minutes and can be confused with dermatographism.
    • Lesions can persist for several hours to up to 48 hours, unlike those in typical urticaria, which resolve within 24 hours.
  • The lesions may be pruritic, painful, or burning.
  • Lesions can occur on any cutaneous surface. Lesions may mimic angioedema.
  • With severe episodes, patients may experience fever, malaise, fatigue, chills, headache, and generalized arthralgias.
  • Affected areas can be refractory to the development of new lesions for 1-2 days.
  • As many as 60% of individuals with delayed pressure urticaria are affected by a concomitant component of chronic idiopathic urticaria, immediate and/or delayed dermatographism, and/or angioedema.

Physical

  • The physical findings in delayed pressure urticaria include wheals, typically involving the palms, soles, legs, and waist. Delayed pressure urticaria lesions may also involve the genitals.
  • The wheals, which appear as deep dermal and subcutaneous swellings, often resemble angioedema more than urticaria.
  • Typical urticaria may also be present as a result of coexisting chronic idiopathic urticaria or some other chronic physical urticaria.

Causes

  • Pressure stimuli may include the following:
    • Standing, walking, or sitting on a hard surface
    • Using tools, such as a screwdriver or a hammer
    • Hand clapping
    • Carrying a handbag
    • Wearing tight-fitting clothes, such as bra straps, belts, shoes, cuffs, or watches
    • Dental work
    • Kissing
    • Sexual intercourse
    • Tampon use
  • Occasionally, delayed pressure urticaria is aggravated by heat, aspirin, or menstruation.

More on Urticaria, Pressure

Overview: Urticaria, Pressure
Differential Diagnoses & Workup: Urticaria, Pressure
Treatment & Medication: Urticaria, Pressure
Follow-up: Urticaria, Pressure
References
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References

  1. Barlow RJ, Warburton F, Watson K, Black AK, Greaves MW. Diagnosis and incidence of delayed pressure urticaria in patients with chronic urticaria. J Am Acad Dermatol. Dec 1993;29(6):954-8. [Medline].

  2. Commins SP, Kaplan AP. Immediate pressure urticaria. Allergy. Jan 2002;57(1):56-7. [Medline].

  3. Lawlor F, Black AK. Delayed pressure urticaria. Immunol Allergy Clin North Am. May 2004;24(2):247-58, vi-vii. [Medline].

  4. Ryan TJ, Shim-Young N, Turk JL. Delayed pressure urticaria. Br J Dermatol. Aug 1968;80(8):485-90. [Medline].

  5. Kaplan AP, Horakova Z, Katz SI. Assessment of tissue fluid histamine levels in patients with urticaria. J Allergy Clin Immunol. Jun 1978;61(6):350-4. [Medline].

  6. Kerstan A, Rose C, Simon D, et al. Bullous delayed pressure urticaria: pathogenic role for eosinophilic granulocytes?. Br J Dermatol. Aug 2005;153(2):435-9. [Medline].

  7. Lawlor F, Bird C, Camp RD, et al. Increased interleukin 6, but reduced interleukin 1, in delayed pressure urticaria. Br J Dermatol. May 1993;128(5):500-3. [Medline].

  8. Di Lorenzo G, Pacor ML, Mansueto P, et al. Is there a role for antileukotrienes in urticaria?. Clin Exp Dermatol. Mar 2006;31(3):327-34.

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

  10. Dover JS, Black AK, Ward AM, Greaves MW. Delayed pressure urticaria. Clinical features, laboratory investigations, and response to therapy of 44 patients. J Am Acad Dermatol. Jun 1988;18(6):1289-98. [Medline].

  11. Grob JJ, Gaudy-Marqueste C. Urticaria and quality of life. Clin Rev Allergy Immunol. Feb 2006;30(1):47-51. [Medline].

  12. Barlow RJ, Ross EL, MacDonald D, Black AK, Greaves MW. Adhesion molecule expression and the inflammatory cell infiltrate in delayed pressure urticaria. Br J Dermatol. Sep 1994;131(3):341-7. [Medline].

  13. Barlow RJ, Ross EL, MacDonald DM, Kobza Black A, Greaves MW. Mast cells and T lymphocytes in chronic urticaria. Clin Exp Allergy. Apr 1995;25(4):317-22. [Medline].

  14. Zuberbier T, Bindslev-Jensen C, Canonica W, et al. EAACI/GA2LEN/EDF guideline: definition, classification and diagnosis of urticaria. Allergy. Mar 2006;61(3):316-20. [Medline].

  15. Zuberbier T, Bindslev-Jensen C, Canonica W, et al. EAACI/GA2LEN/EDF guideline: management of urticaria. Allergy. Mar 2006;61(3):321-31. [Medline].

  16. Lawlor F, Black AK, Ward AM, Morris R, Greaves MW. Delayed pressure urticaria, objective evaluation of a variable disease using a dermographometer and assessment of treatment using colchicine. Br J Dermatol. Mar 1989;120(3):403-8. [Medline].

  17. Hartmann K, Hani N, Hinrichs R, Hunzelmann N, Scharffetter-Kochanek K. Successful sulfasalazine treatment of severe chronic idiopathic urticaria associated with pressure urticaria. Acta Derm Venereol. Jan-Feb 2001;81(1):71. [Medline].

  18. Kozel MM, Sabroe RA. Chronic urticaria: aetiology, management and current and future treatment options. Drugs. 2004;64(22):2515-36. [Medline].

  19. Kulthanan K, Thumpimukvatana N. Positive impact of chloroquine on delayed pressure urticaria. J Drugs Dermatol. Apr 2007;6(4):445-6. [Medline].

  20. Dawn G, Urcelay M, Ah-Weng A, O'Neill SM, Douglas WS. Effect of high-dose intravenous immunoglobulin in delayed pressure urticaria. Br J Dermatol. Oct 2003;149(4):836-40. [Medline].

  21. Nettis E, Colanardi MC, Soccio AL, Ferrannini A, Vacca A. Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule, and is effective in the treatment of delayed pressure urticaria: a randomized, double-blind, placebo-controlled study. Br J Dermatol. Dec 2006;155(6):1279-82. [Medline].

  22. Vena GA, Cassano N, D'Argento V, Milani M. Clobetasol propionate 0.05% in a novel foam formulation is safe and effective in the short-term treatment of patients with delayed pressure urticaria: a randomized, double-blind, placebo-controlled trial. Br J Dermatol. Feb 2006;154(2):353-6. [Medline].

  23. Czarnetzki BM, Meentken J, Kolde G, Brocker EB. Morphology of the cellular infiltrate in delayed pressure urticaria. J Am Acad Dermatol. Feb 1985;12(2 Pt 1):253-9. [Medline].

  24. Estes SA, Yung CW. Delayed pressure urticaria: an investigation of some parameters of lesion induction. J Am Acad Dermatol. Jul 1981;5(1):25-31. [Medline].

  25. Sussman GL, Harvey RP, Schocket AL. Delayed pressure urticaria. J Allergy Clin Immunol. Nov 1982;70(5):337-42. [Medline].

  26. Warin RP. A simple out-patient test for delayed pressure urticaria. Br J Dermatol. May 1987;116(5):742-3. [Medline].

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Further Reading

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Keywords

urticaria, pressure urticaria, delayed pressure urticaria, DPU, PU, chronic idiopathic urticaria, physical urticaria, vibratory urticaria, dermatographism

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Contributor Information and Disclosures

Author

Joslyn S Kirby, MD, Assistant Professor, Department of Dermatology, Milton S Hershey Penn State Medical Center
Joslyn S Kirby, MD is a member of the following medical societies: American Academy of Dermatology, International Society for Cutaneous Lymphomas, Pennsylvania Academy of Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ellen J Kim, MD, Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania
Ellen J Kim, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Dermatology Foundation, Medical Dermatology Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Robin M Levin, MD, Staff Physician, Assistant Professor, Department of Family Medicine, Division of Dermatology, Kennedy Hospital at Stratford
Robin M Levin, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; Investigator, Hill Top Research, Florida Research Center
Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
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

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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