eMedicine Specialties > Dermatology > Allergy & Immunology

Urticaria, Papular

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jun 2, 2009

Introduction

Background

Papular urticaria is a common and often annoying disorder manifested by chronic or recurrent papules caused by a hypersensitivity reaction to the bites of mosquitoes, fleas, bedbugs, and other insects. Individual papules may surround a wheal and display a central punctum.1 Papular urticaria tends to be evident during spring and summer months. However, in some climates, such as in San Francisco, California, this condition may affect children throughout the year.

Papular urticaria.

Papular urticaria.

[ CLOSE WINDOW ]
Papular urticaria.

Papular urticaria.


Other eMedicine articles on urticarias include Urticaria, Acute; Urticaria, Cholinergic; Urticaria, Contact Syndrome; Urticaria, Dermographism; Urticaria, Chronic; Urticaria, Pressure; and Urticaria, Solar.

Pathophysiology

The histopathologic pattern in papular urticaria consists of mild subepidermal edema, extravasation of erythrocytes, interstitial eosinophils, and exocytosis of lymphocytes. These findings suggest a pathophysiologic process that is immunologically based.1 Papular urticaria is generally regarded to be the result of a hypersensitivity or id reaction to bites from insects,2 such as mosquitoes, gnats, fleas,3,4 mites,5,6 and bedbugs.7,8 Varicella vaccines have also been implicated.9

Morphologic and immunohistochemical evidence suggest that a type I hypersensitivity reaction plays a central role in the pathogenesis of papular urticaria. The reaction is thought to be caused by a hematogenously disseminated antigen deposited by an arthropod bite in a patient who is sensitive. This theory is supported by the fact that these lesions can and often do occur in areas away from the bites. The putative antigen is unknown.

The presence of immunoglobulin and complement deposits in the skin of some patients with papular urticaria suggests that the lesions may be due to a cutaneous vasculitis.10 The deposits were most frequently seen in lesions within 24 hours of their development. The presence of granular deposits of Clq, C3, and immunoglobulin M (IgM) in superficial dermal blood vessel walls suggests that immune complexes (IgM aggregates) may be primarily involved in the pathogenesis, with complement activation initiated by Clq through the classic pathway.

A Th2 shift may be present, similar to what is observed in atopy.4

Frequency

United States

The incidence is unknown.

International

The incidence is unknown.

Mortality/Morbidity

The main morbidity is the discomfort due to localized pruritus.

Race

No racial predisposition is known, although certain ethnic groups, specifically Asians, may be more predisposed to more intense reactions.

Sex

No sexual predisposition is known; however, a small study from Nigerian reported a slight female predominance for skin diseases such as papular urticaria and atopic dermatitis.11

Age

This eruption occurs primarily in children, but they eventually outgrow this disease, probably through desensitization after multiple arthropod exposures.12,13 This condition, however, can also occur in adults, albeit at a much lower rate.

Clinical

History

Patients report usually chronic or recurrent episodes of a papular eruption that tends to occur in groups or clusters associated with intense pruritus.

Children, adult males, nonlocals, and those belonging to urban or periurban areas may be more vulnerable to papular urticaria.14 The most common first appearance is of papules and urticarial plaques in clusters over exposed  and covered parts of the body.

Physical

  • Papular urticaria is characterized by crops of symmetrically distributed pruritic papules and papulovesicles. The lesions can also appear in an area localized to the site of insect bites.
  • Papules may occur on any body part, but they tend to be grouped on exposed areas, particularly the extensor surfaces of the extremities.
  • Scratching may produce erosions and ulcerations.
  • Secondary impetigo or pyoderma is common.

Causes

A hypersensitivity reaction to the bites of mosquitoes, fleas, bedbugs, and other insects causes papular urticaria. It is unusual to identify an actual culprit in any given patient.15,16

More on Urticaria, Papular

Overview: Urticaria, Papular
Differential Diagnoses & Workup: Urticaria, Papular
Treatment & Medication: Urticaria, Papular
Follow-up: Urticaria, Papular
Multimedia: Urticaria, Papular
References
[ CLOSE WINDOW ]

References

  1. Stibich AS, Schwartz RA. Papular urticaria. Cutis. Aug 2001;68(2):89-91. [Medline].

  2. Lewis-Jones MS. Papular urticaria caused by Dermestes maculatus Degeer. Clin Exp Dermatol. Mar 1985;10(2):181. [Medline].

  3. Garcia E, Halpert E, Rodriguez A, Andrade R, Fiorentino S, Garcia C. Immune and histopathologic examination of flea bite-induced papular urticaria. Ann Allergy Asthma Immunol. Apr 2004;92(4):446-52. [Medline].

  4. Cuellar A, Rodriguez A, Rojas F, Halpert E, Gomez A, Garcia E. Differential Th1/Th2 balance in peripheral blood lymphocytes from patients suffering from flea bite-induced papular urticaria. Allergol Immunopathol (Madr). Jan-Feb 2009;37(1):7-10. [Medline].

  5. Burns DA. Papular urticaria produced by the mite Listrophorus gibbus. Clin Exp Dermatol. May 1987;12(3):200-1. [Medline].

  6. Yoshikawa M. Skin lesions of papular urticaria induced experimentally by Cheyletus malaccensis and Chelacaropsis sp. (Acari: Cheyletidae). J Med Entomol. Jan 18 1985;22(1):115-7. [Medline].

  7. Jordaan HF, Schneider JW. Papular urticaria: a histopathologic study of 30 patients. Am J Dermatopathol. Apr 1997;19(2):119-26. [Medline].

  8. Demain JG. Papular urticaria and things that bite in the night. Curr Allergy Asthma Rep. Jul 2003;3(4):291-303. [Medline].

  9. Bronstein DE, Cotliar J, Votava-Smith JK, Powell MZ, Miller MJ, Cherry JD. Recurrent papular urticaria after varicella immunization in a fifteen-month-old girl. Pediatr Infect Dis J. Mar 2005;24(3):269-70. [Medline].

  10. Heng MC, Kloss SG, Haberfelde GC. Pathogenesis of papular urticaria. J Am Acad Dermatol. Jun 1984;10(6):1030-4. [Medline].

  11. Altraide DD, George IO, Frank-Briggs AI. Prevalence of skin diseases in Nigerian children--(the University of Port Harcourt Teaching Hospital) experience. Niger J Med. Oct-Dec 2008;17(4):417-9. [Medline].

  12. Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatology. J Am Acad Dermatol. Jun 2004;50(6):819-42, quiz 842-4. [Medline].

  13. Howard R, Frieden IJ. Papular urticaria in children. Pediatr Dermatol. May-Jun 1996;13(3):246-9. [Medline].

  14. Raza N, Lodhi MS, Ahmed S, Dar NR, Ali L. Clinical study of papular urticaria. J Coll Physicians Surg Pak. Mar 2008;18(3):147-50. [Medline].

  15. Naimer SA, Cohen AD, Mumcuoglu KY, Vardy DA. Household papular urticaria. Isr Med Assoc J. Nov 2002;4(11 Suppl):911-3. [Medline].

  16. Lembo S, Panariello L, d'Errico FP, Lembo G. Professional's and non-professional's papular urticaria caused by Scleroderma domesticum. Contact Dermatitis. Jan 2008;58(1):58-9. [Medline].

  17. [Guideline] American Academy of Allergy, Asthma & Immunology. Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help. J Allergy Clin Immunol. Feb 2006;117(2 Suppl Consultation):S495-523. [Medline].

  18. Giraldi S, Ruiz-Maldonado R, Tamayo L, Sosa-de-Martinez C. Oral desensitization in papular urticaria in children. Trop Doct. Jul 2002;32(3):142-5. [Medline].

  19. Smith SR, Macfarlane AW, Lewis-Jones MS. Papular urticaria and transfer of allergy following bone marrow transplantation. Clin Exp Dermatol. Jul 1988;13(4):260-2. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

urticaria, papular urticaria, insect bites, type I hypersensitivity reaction, id reaction, bug bites

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Alexa F Boer Kimball, MD, MPH, Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital and Brigham and Women's Hospital
Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, 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

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.