Laboratory Studies

An elevated white blood cell (WBC) count or neutrophilia may be present.^{[25, 26]}Complement levels are normal.

Some patients with delayed pressure urticaria (DPU) also have concomitant chronic idiopathic urticaria (CIU). Basic testing for CIU includes CBC count with differential, erythrocyte sedimentation rate, and/or C-reactive protein. Extended diagnostic testing includes the following^{[20, 27]}:

Thyroid function tests and antibody testing for autoimmune thyroid disease
Antibody testing for Helicobacter pylori
Autoantibody to IgE
Allergy testing (skin tests and/or allergen avoidance tests)

Pressure Challenge Testing

Pressure challenge testing (with the dermographometer or the suspended-weight method) may be performed for delayed pressure urticaria (DPU). Because therapy may influence test results, it is recommended that testing be performed at a time when therapy has been interrupted or stopped for at least 3 days; 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 DPU. A consensus conference review suggests using the following approaches^[20]:

A shoulder strap 3 cm wide with a 7-kg weight for 15 minutes
A rod 1.5 cm in diameter with a 2.5-kg weight for 15 minutes
A rod 6.5 cm in diameter with a 5-kg weight for 15 minutes
A dermographometer to a pressure of 100 g/mm² for 70 seconds

The tests are most often applied to the shoulders, upper back, posterior thighs, or volar forearm. Pressure provocation tests should be read at 6 hours. Both the weight and the application time should be recorded. The duration of application is inversely related to the pressure applied; for example, wheals take longer to develop with a lower pressure than with a higher pressure.

Histologic Findings

The histologic features of delayed pressure urticaria (DPU) lesions are variable, often depending 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 DPU lesion (>24 h) demonstrates eosinophils and lymphocytes.

No vessel-related changes (eg, leukocytoclasia or fibrinoid necrosis), such as those noted in urticarial vasculitis, are seen. Direct immunofluorescence test results are negative.

Several reports of bullous pressure urticaria have been reported, and histologic findings show spongiosis and intraepidermal bullae associated with an eosinophil-rich inflammatory infiltrate in the superficial and deep dermis.^[10]

Treatment & Management

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Media Gallery

Delayed pressure urticaria. Courtesy of DermNet New Zealand (http://www.dermnetnz.org/assets/Uploads/reactions/pressure2.jpg).

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Author

Sarah Beggs, MD Resident Physician, Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University

Disclosure: Nothing to disclose.

Coauthor(s)

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Niraj Butala, MD Resident Physician, Department of Dermatology, Cooper University Hospital

Niraj Butala, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Acknowledgements

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