Swelling after urticaria
Hives Is a rash, the element of which is the blister: a clearly limited section of the edema of the dermis with uneven, raised borders, surrounded by a zone of hyperemia and having a paler color in the center. Elements of the rash can merge, forming large blisters.
Edema Quincke captures limited, but more extensive areas and extends not only to the dermis, but also to the subcutaneous tissue. With pressure, the fossa does not remain.
Both urticaria and Quincke's edema - cutaneous manifestations of local edema, appearing together or separately; sometimes there is a similar swelling of the mucosa of the upper respiratory tract and gastrointestinal tract.
Urticaria and angioedema can be acute (symptoms persist for less than 6 weeks) and chronic (more than 6 weeks) course.
Although hives can occur in anyage, more often it occurs in adults, especially at the age of 20 - 30 years. According to a study conducted among university students, 15 to 20% of them had urticaria at least once in their life.
At the basis of both hives and edema of Quincke lieallergic reactions of immediate type (interaction of IgE with an allergen or IgG with foreign IgA), as well as other, immune and non-immune mechanisms. Since the cause of chronic urticaria can not be established in most cases, it is often called idiopathic.
Acute hives and Quincke's edema that occur whenallergies to the epidermis of animals and molds, or in the event of an exacerbation of seasonal allergic respiratory diseases, may be due to the contact of allergens with the skin or their ingress onto the respiratory mucosa.
However, the ingestion of allergens in the gastrointestinal tract leads tourticaria and Quinck's swelling are much more frequent than their inhalation. Eating raw fruits, shellfish, fish, dairy products, chocolate, legumes (for example, peanuts) and ingesting certain medicines may lead not only to acute or chronic urticaria and Quinck's edema, but also to anaphylactic reactions with severe gastrointestinal manifestations.
There are several forms of hives caused by physical factors:
- urticaria caused by mechanical irritation
- hives caused by cold
- hives caused by heat
- urticaria caused by sunlight
- urticaria caused by physical exertion
The data of the anamnesis and a clinical picture allow to distinguish these forms of a urticaria from an allergic urticaria.
Urticaria dermographism. is characterized by the appearance of a blister in the place of mechanical skin irritation caused by the blunt object carried along it.
Prevalence of urticaria dermographismis 1 - 4%, most often it is observed at the age of 10 - 30 years. In persons with atopic diseases, this form of urticaria occurs with the same frequency as in the general population. Within 5 years, it usually passes.
Hives from pressure. manifested by blisters in areas of prolongedpressing on the skin, on the shoulders - after wearing a bag on a belt or clothes with straps, on the feet - after walking or running, on the palms - after manual labor. This form of urticaria often accompanies urticaria dermographism and chronic idiopathic urticaria.
Cholinergic urticaria. is shown by small (1 - 2 mm) itchingblisters, surrounded by wide rings of erythema. The appearance of a rash leads to an increase in body temperature, for example, with fever, physical exertion, after a hot bath or shower.
Anaphylactic reaction caused by physical effort. begins with erythema and itchy blisters withthe subsequent development of Quincke's edema (can spread to the face, oropharynx, larynx, intestinal wall) or shock. Blisters with this reaction are larger than with cholinergic urticaria, and appear only with physical stress.
Cold urticaria. (familial or sporadic) is manifested by a rashon the area of the skin subjected to cooling, for example, in contact with an ice cube or cold water. Cooling the whole body, for example when swimming in cold water, can lead to shock.
Solar Urticaria. which can be conditionally divided into three versions depending on the range of light that causes the appearance of the rash:
- sensitivity to UVA
- sensitivity to UV-B
- sensitivity to visible light
Vibrational edema of Quincke may occursuddenly, or develop in individuals who have been exposed to vibration for several years. This disease is often associated with cholinergic urticaria.
Among the rare forms of hives caused by physical factors, it can be noted:
- thermal urticaria
- Aquatic urticaria (occurs under the action of water of any temperature)
- contact urticaria (occurs when the skin contacts certain substances)
Congenital and acquired deficiency of the C1-esterase inhibitor can lead to the development of edema Quincke, which is usually not accompanied by the appearance of urticaria.
Urticaria and Quincke's Edema. Serum disease and urticarial vasculitis. are apparently caused by immunocomplex allergic reactions leading to deficiency of complement components.
To the appearance of a rash, and sometimes anaphylactoid reactions can lead idiosyncratic action of NSAIDs and drugs causing direct degranulation of mast cells .
Pathogenesis and symptoms of urticaria
Hives can occur on any siteBody, including the scalp and foot. However, most often hives appear on the hands, feet, external genitals and face, especially around the eyes and mouth.
In the clinical picture of urticaria and edema Quincke - the following characteristic symptoms prevail.
Itching - Hives are usually accompanied by severe itching.
Rashes - with urticaria sometimes appear as waves and persist for 24 to 72 hours, but individual elements of the rash last no more than 24 hours.
Residual skin color change for hives and Quincke's edema is uncharacteristic, unless they are accompanied by a disease accompanied by diapedesis of erythrocytes.
Although Quincke's edema also does not last long, it is classified as life-threatening conditions, since it can lead to obstruction of the upper respiratory tract.
If the edema of Quincke affects the gastrointestinal tract, then sometimes there are cramping abdominal pain, nausea, or vomiting. which can be mistaken for a condition requiring surgical intervention.
Pathogenetic classification of urticaria and edema Quincke
- Hives and Quincke's edema caused byallergic reactions of immediate type, for example, reactions to pollen, food products, medicines, fungi, poisons of Hymenoptera, helminths and other allergens, as well as blood transfusion to individuals with isolated IgA deficiency
- Urticaria and Quincke's edema caused by complement activation
- Hereditary edema of Quincke of types I and I I
- Acquired Quincke's edema caused by lymphoproliferative diseases and autoantibodies to the C1-esterase inhibitor
- Urticaria Vasculitis
- Serum sickness
- Transfusion of blood components
- Urticaria and Quincke's edema caused by non-immune mechanisms
- Urticaria and Quincke's edema caused by physicalfactors: urticar dermographism, pressure urticaria, cold urticaria, solar urticaria, cholinergic urticaria, vibrational edema of Quincke, anaphylactic reaction caused by physical effort
- Urticaria and Quincke's edema caused bydrugs that activate degranulation of mast cells: opioids, antimicrobial agents, muscle relaxants (eg, tubocurarine), radiocontrast agents
- Hives and Quincke's edema caused by drugs and other substances that affect the metabolism of arachidonic acid: aspirin and other NSAIDs, azo dyes, benzoic acid salts
- Idiopathic Urticaria and Quincke's Edema
In histological examination affected areas are visible loosenedcollagen fibers, dilated vessels and perivascular infiltrates from lymphocytes, eosinophils and neutrophils. The ratio of cells in infiltrates in different parts of the tissue is not the same.
Among all forms of urticaria mediated by degranulation of mast cells, perhaps the best studied pathogenesis of cold urticaria. In some patients suffering from thisin the serum, cryoglobulins are detected. On the site of the hand, immersed in ice water, Quincke's edema develops for several minutes, and urticaria on the site that is not in contact with water. Histological examination reveals massive degranulation of mast cells and edema of the dermis and subcutaneous tissue.
In the venous blood of a chilled hand, the concentration of histamine rises significantly, while in the blood flowing by hand, not exposed to cold, histamine is absent.
With urticar dermographism, hives frompressure, vibrational edema of the Quincke, solar and thermal urticaria in the blood flowing from the affected areas of the skin, and in the contents of the blisters created on the skin with the help of vacuum, histamine is also found.
Morphological changes in mast cells,observed during their degranulation, with cold urticaria and urticarum dermographism are not the same. In cold urticaria degranulation of mast cells proceeds in the same way as in allergic reactions of immediate type: the contents of the granules become amorphous, they merge with each other and with the cell membrane and release all the contents into the extracellular space.
With urticar dermographism, along with thesechanges are observed fragmentation of granules - from them buds smaller buds that later also release their contents into the extracellular space.
In one study it was shown that whencholinergic urticaria and anaphylactic reaction caused by physical effort (these conditions were called experimentally when running on a treadmill in a suit for underwater swimming), histamine appears in the blood, and degranulation of mast cells occurs in the skin. In this case, the violation of the function of external respiration was noted only with cholinergic urticaria.
Urticaria and Quincke's edema develop suddenly and are of a transient nature.
For Hives characterized by a wavy appearance of new rashes (therefore, in one area of the skin there are blisters that are at different stages of development), and for the edema Quincke Asymmetric localization.
Preliminary diagnosis of urticaria and Quincke edema due to allergic reactions of immediate type can be made according to anamnesis indicating recent contact with the allergen.
To confirm the diagnosis, skin tests are performedor examine the serum for the presence of specific IgE in it. Sometimes the overall level of IgE and the number of eosinophils in the blood are determined, but not all patients have an increase in these parameters.
In the diagnosis of urticaria caused by physical factors, the leading role is played by provocative tests, which usually make it possible to establish the cause of the rash.
Differential diagnosis of urticaria and edema of Quincke
The principles of differential diagnosis of various forms of urticaria and Quincke's edema are based on their pathogenetic classification.
Whenurticaria and Quincke's edema. mediated allergic reactions of immediate type. the content of complement components remains normal, while with immunocomplex allergic reactions and hereditary deficiency of the C1-esterase inhibitor it decreases.
The combination of symptoms such as chronic urticaria, arthralgia, increased ESR, sometimes deficiency of complement components, is typical for Urticaria vasculitis. which is more often observed in women. In this disease, blisters can persist for more than 72 hours, while in other forms of urticaria they disappear no later than 24 to 48 hours. To confirm the diagnosis of urticarial vasculitis, a skin biopsy is performed. Histological examination reveals cellular infiltration, leukoclasia and fibrinoid necrosis of venule walls.
The same histological pattern is observed when urticaria. arising on the background of SLE and viral hepatitis .
Appearance urticariawith serum sickness accompanied by fever, an increase in lymph nodes, myalgia, arthralgia and arthritis.
Hives that occur after transfusion of blood components and injections of normal immunoglobulin for IVadministration, usually passes quickly and is not accompanied by more severe systemic manifestations, unless it is caused by an IgA deficiency or by the aggregation of immunoglobulins.
Hereditary edema of Quincke - an autosomal dominant disease that canbe due to a deficit (hereditary type I Quincke edema) or functional insufficiency (hereditary type II Quincke edema) of the C1-esterase inhibitor.
The most common hereditary type I Quincke edema. Preliminary diagnosis can be made bydata of a family history and clinical picture of the disease, characterized by exacerbations, accompanied by cramping pain in the abdomen and swelling of the larynx.
Itching and urticaria for the hereditary edema of Quincke are uncharacteristic.
The final diagnosis is made whendeficiency or functional insufficiency of the C1-esterase inhibitor. Concentrations of C2 and C4 (substrates of C1-esterase) in this disease are reduced. During exacerbations, the activity of C1-esterase increases, which leads to an even greater decrease in the concentrations of these complement components. Since the C1-esterase inhibitor also inhibits the activation of plasmin, coagulation factor XII and kallikrein, the role of bradykinin and kinin, derived from C2b under the action of plasmin, can play a role in the pathogenesis of hereditary edema of Quincke.
Acquired deficiency of the C1-esterase inhibitor with B-cell lymphomas and leukemia is manifestedthe same clinical picture as the hereditary edema of Quincke, but not of a family nature. In the serum of such patients, the concentrations of not only C2, C4 and the C1-esterase inhibitor, but also C1, were reduced, and anti-idiotypic antibodies to monoclonal immunoglobulins on the surface of transformed B-lymphocytes were also detected.
Another form of acquired deficiency of the C1-esterase inhibitor is due to the appearance of autoantibodies (IgG) in the serum of patients with it and is not associated with lymphoproliferative diseases.
Allergic contact dermatitis. with which often it is necessary to differentiate hives and Quincke's edema, manifests itself as blisters and papules on the skin, and with prolonged contact with the allergen-the lichenization of the affected area.
In addition, hives and Quincke's edema must be differentiated with diffuse neurodermatitis. which is manifested in an acute stageredness and swelling of skin areas, the appearance of papules, vesicles and mocculation on it, and in subacute and chronic - peeling, cracks and lichenization (a rash that is characteristic of the acute stage is weak or absent). Defeat in diffuse neurodermatitis is more often localized on the flexural surface of the arms and legs.
A differential diagnosis with pigmentary urticaria (a form of generalized cutaneous mastocytosis) andsystemic mastocytosis. With pigmentary urticaria on the skin appear red-brown spots and papules, and with mechanical irritation - itchy blisters. With systemic mastocytosis (in combination with pigmentary urticaria or in its absence) hives may appear during hot flashes, but edema, like Quincke's edema, is uncharacteristic for this disease.