Pressure Urticaria Workup

  • Author: Joslyn S Kirby, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 25, 2011
 

Laboratory Studies

  • An elevated white blood cell count and/or neutrophilia may be present.[16, 17]
  • Complement levels are normal.
  • Some patients with delayed pressure urticaria (DPU) also have concomitant chronic idiopathic urticaria (CIU). The following ancillary testing can be helpful in patients with chronic idiopathic urticaria[18, 19] :
    • The erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be elevated.
    • Thyroid function tests and antibody testing for autoimmune thyroid disease may return positive results.
    • Antibody testing for Helicobacter pylori can be performed. If results are positive, the infection should be treated.
    • Anti-immunoglobulin E autoantibody testing can be performed.
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Other Tests

Pressure challenge testing (dermographometer, suspended-weight method) may be performed for delayed pressure urticaria.[20] As therapy may influence test results, it is recommended testing be performed during an interruption or cessation of therapy. However, some patients may have more severe disease that does not allow this. Repetitive testing can be used to assess response to therapy.

Multiple methods of applying measured amounts of pressure can be used to test for the development of delayed pressure urticaria. A consensus conference review[18] suggests using the following:

  • Shoulder strap of 3 cm width and weight of 7 kg for 15 minutes
  • Rod of 1.5 cm diameter with weight of 2.5 kg for 15 minutes
  • Rod of 6.5 cm diameter with weight of 5 kg for 15 minutes
  • Dermographometer to 100 g/mm2 for 70 seconds

The tests are most often applied to the shoulders, upper back, posterior thighs, and/or volar forearm. Pressure provocation tests should be read at 6 hours. Both the weight and application time should be recorded since the time of application and pressure are inversely related. For example, wheals will take longer to develop with lesser pressure than with greater pressure.

Several scoring systems are used to measure the severity of chronic urticaria in studies as well as in practice. A European panel suggested the assessment tool in the Table below.

Table. Assessment Tool for Scoring* Severity of Disease[19] (Open Table in a new window)

ScoreWhealsPruritus
0NoneNone
1Mild (< 20 wheals/24 h)Mild
2Moderate (21-50 wheals/24 h)Moderate
3Intense (>50 wheals/24 h) or large confluent areasIntense
*Score = wheal score (0-3) + pruritus score (0-3); score range is 0-6.

The severity of delayed pressure urticaria can vary throughout the day and from day to day. Overall disease activity is best assessed by having patients determine a severity score several times a day for several days prior to appointments.

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Histologic Findings

The histologic features of the delayed pressure urticaria lesions are variable, often dependent on the age of the lesion.

  • Biopsy within hours demonstrates moderate-to-heavy infiltration of eosinophils with neutrophils and lymphocytes in a perivascular and interstitial pattern in the dermis and subcutaneous fat. Degranulated mast cells may be noted.
  • Biopsy of an older delayed pressure urticaria lesion (>24 h) demonstrates eosinophils and lymphocytes.
  • No vessel-related changes (eg, leukocytoclasis, fibrinoid necrosis) are seen, such as in urticarial vasculitis.
  • Direct immunofluorescence test results are negative.
  • Several reports of bullous pressure urticaria have been reported, and histology findings show spongiosis and intraepidermal bullae associated with an eosinophil-rich inflammatory infiltrate in the superficial and deep dermis.[6]
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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-New Jersey Medical School

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.

Specialty Editor Board

Daniel J Hogan, MD  Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; 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.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at 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.

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.

References

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  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. Kasperska-Zajac A, Brzoza Z, Rogala B. Increased concentration of platelet-derived chemokines in serum of patients with delayed pressure urticaria. Eur Cytokine Netw. Jun 2008;19(2):89-91. [Medline].

  10. Kasperska-Zajac A, Jasinska T. Analysis of plasma D-dimer concentration in patients with delayed pressure urticaria. J Eur Acad Dermatol Venereol. Feb 2011;25(2):232-4. [Medline].

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  15. Czecior E, Grzanka A, Kurak J, Misiolek M, Kasperska-Zajac A. Late Dysphagia and Dyspnea as Complications of Esophagogastroduodenoscopy in Delayed Pressure Urticaria: Case Report. Dysphagia. Jun 5 2011;[Medline].

  16. 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].

  17. 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].

  18. Magerl M, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, Mathelier-Fusade P. The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations. Allergy. Dec 2009;64(12):1715-21. [Medline].

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

  20. 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].

  21. Liu RH, Werth VP. What is new in the treatment of steroid-induced osteoporosis?. Semin Cutan Med Surg. Dec 2007;26(4):203-9. [Medline].

  22. 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].

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

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  25. 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].

  26. Metz M, Altrichter S, Ardelean E, Kessler B, Krause K, Magerl M, et al. Anti-immunoglobulin E treatment of patients with recalcitrant physical urticaria. Int Arch Allergy Immunol. 2011;154:177-80.

  27. Mitzel-Kaoukhov H, Staubach P, Müller-Brenne T. Effect of high-dose intravenous immunoglobulin treatment in therapy-resistant chronic spontaneous urticaria. Ann Allergy Asthma Immunol. Mar 2010;104(3):253-8. [Medline].

  28. 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].

  29. 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].

 
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Table. Assessment Tool for Scoring* Severity of Disease[19]
ScoreWhealsPruritus
0NoneNone
1Mild (< 20 wheals/24 h)Mild
2Moderate (21-50 wheals/24 h)Moderate
3Intense (>50 wheals/24 h) or large confluent areasIntense
*Score = wheal score (0-3) + pruritus score (0-3); score range is 0-6.
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