The Journal of Allergy and Clinical Immunology: In Practice
Review and Feature ArticleHow to Approach Chronic Inducible Urticaria
Section snippets
Pathophysiology of CIndU
The exact pathological mechanisms that result in CIndU are still under investigation. The activation and degranulation of tissue-resident mast cells and the subsequent release of proinflammatory mediators such as histamine play key roles.8, 9, 10, 11 The efficacy of anti-IgE (omalizumab) in many patients with CIndU points to a possible role of IgE in the degranulation of mast cells in CIndU. Type I autoimmunity, also known as autoallergy, is held by many to be of major importance in the
Clinical features
SD (synonym: urticaria factitia, dermographic urticaria) is the most common physical urticaria and characterized by itching and/or burning skin sensations and the development of itchy wheals in response to rubbing, scratching, and/or scrubbing, that is, shearing forces acting on the skin. In very rare cases, angioedema can develop. SD is clinically distinct from the more common “simple” dermographism, where whealing, but no itch sensation, occurs after firm stroking of the skin. White
Clinical features
ColdU (synonym: acquired ColdU or cold contact urticaria) is characterized by the appearance of wheals after contact with cold or cooling and rewarming of the skin (Table II).43, 44, 45, 46 ColdU is the second most frequent subtype of physical urticaria. The annual incidence is 0.05%47 with predominant manifestation in young adults and slightly higher prevalence in women.6 The clinical symptoms occur within minutes after skin contact with cold air, cold liquids, cold solid objects, or
Clinical features
CholU is characterized by itching, redness, and papular whealing induced by exercise and passive warming (eg, hot bath). Emotional stress as well as spicy and hot food can also provoke these symptoms. Typically, these patients show tiny, short-lived wheals with a pronounced flare reaction that is frequently localized to the trunk and extremities83, 84, 85, 86, 87, 88, 89, 90 (Figure 2, G and H) and lasts for 15-60 minutes. But other morphological patterns, including angioedema and systemic
Clinical features
Patients with DPU develop delayed cutaneous erythema and edema with often marked subcutaneous swelling after a pressure stimulus. When this swelling involves the hands or feet, it is indistinguishable from angioedema. Pressure-induced lesions typically occur 4 to 6 hours later, but may occur as early as 30 minutes and last up to 48 hours.110 It is important to note that many patients with DPU also have concomitant CSU and angioedema, and hence many of their lesions may not be exclusively
Outlook and Unmet Needs
Over the past few years, novel tools for the diagnostic workup and new treatment options for patients with SD, ColdU, CholU, and DPU have become available. Less frequent forms of CIndU, however, are still in need of further studies and the development of tools to better manage them in clinical practice.20, 73, 90 Standardized provocation and threshold testing protocols need to be developed for all CIndUs. Their use in diagnosing and monitoring CIndUs helps physicians and patients to understand
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No funding was received for this work.
Conflicts of interest: M. Maurer has received institutional research funding and/or honoraria for consulting/lectures from Allakos, FAES, Genentech, Menarini, MOXIE, Novartis, Sanofi, and Uriach, all outside the current work. J.W. Fluhr declares no conflicts of interest. D.A. Khan has received speaker honoraria from Genentech, outside the current work.