Hives: Not just skin-deep
Urticaria can be annoying or even alarming sometimes. Take, for example, you’re in the middle of your routine exercise like jogging and suddenly, you develop a lot of elevated, reddish wheals (pantal) on your thigh that progressively increase in number and itch. The intensity of the itch increases as you jog further. Or when you’re on a date with your crush and you suddenly develop swelling on your lips while taking a sip of your favorite ice cold juice. It may be as simple as a localized swelling after being stung by a wasp on the hand or it can be more upsetting like when you develop severe swelling of your eyes, lips, hands, and feet, accompanied by a change in your voice when you’re lecturing somewhere out of the country. Or it could be a very troublesome event disrupting your daily activities as these rashes seem to appear day in and day out.
Within the last decade, there has been a flurry of research into what causes itchy hives (wheals) and how to stop it. The concern was not so much about the fleeting itchiness of insect bites or the nasty pruritic skin caused by contactants as it was about the unending misery caused by chronically recurring itching and whealing disturbing your sleep. The kind that does not go away and torments people night and day, and more often resists remedies like steroid creams or oral antihistamines.
Urticaria (pantal or tagulabay) is defined as intense, itching welts caused by allergic reactions to internal and external agents. It is a highly prevalent condition, resulting in large numbers of medical consultations worldwide. Its prevalence ranges between 0.3 and 11.3%. It has been estimated that approximately 15 to 25% of the population will experience an episode of acute urticaria at some point in their lifetime. Although urticaria has a tremendous impact on the patient’s quality of life, it is often disregarded as a trivial disease by many physicians. The results are patients not adequately educated on the nature of their condition and its proper management, which involves not only pharmacological treatment but also the implementation of preventive measures to reduce the effects of various precipitating and aggravating factors. Most acute urticaria (less than six to eight weeks) are manageable while the chronic type (more than six to eight weeks) is sometimes very debilitating and difficult to treat.
Angioedema may co exist with urticaria. This is a form of urticaria in which there is deeper swelling in the skin, and the swelling may take longer than 24 hours to clear. It involves rapid swelling (edema) of the dermis (2nd layer of skin), subcutaneous tissue (3rd layer of skin), mucosa, submucosal tissues (inner mouth, tongue etc.). It is very similar to urticaria, but urticaria occurs in the upper dermis (the more superficial part of the skin’s 2nd layer). Angioedema is life-threatening as it can swell up the tongue, the airway passages, and other different organs such as the gastrointestinal tract which can lead to decreased oxygenation, difficulty in breathing, dehydration due to severe diarrhea, and eventually death.
An individual may have urticaria (pantal) alone, angioedema alone, or both together. All are caused by the release of histamine from cells in the skin called mast cells. When angioedema occurs in association with urticaria, the two conditions can be considered part of the same process. When angioedema occurs on its own, different causes need to be considered.
There are different types of urticaria but the most common is that type whose cause is not known, meaning the cause cannot be determined (idiopathic urticaria). This occurs in about 95% of cases and is often accompanied by deeper swelling (angioedema). Authorities believe that an autoimmune process (one involving the body’s reaction on itself like lupus) is involved in up to 50% of patients. In others, multiple factors play a significant role. Some patients have asthma, which makes them more prone to cells that burst upon a stimuli, releasing histamine. Others have features of cholinergic urticaria (pantal triggered by sweat, heat, exercise, emotional stress). In cases of chronic idiopathic urticaria, search for other causes may benefit the patient. These include mostly autoimmune diseases (like lupus, Hashimoto’s thyroiditis etc.), cryoglobulinemia, a medical condition in which the blood contains large amounts of cryoglobulins-proteins (mostly immunoglobulins themselves) that become insoluble, leading to the slowing and blockage of blood flow at reduced body temperatures, lymphoma (cancer of the blood that originates from a part of the immune system called the lymph system), vasculitis (a group of disorders that destroys blood vessels by inflammation), and the presence of infections (bacterial, fungal, viral).
In some cases, the cause is easy to pinpoint as in the case of physical urticarias. Physical urticaria is triggered primarily by physical stimuli (e.g. pressure on the skin like welts on panty lines, bra lines after a day’s work), vibration, cold, localized heat, sunlight, and water (aquagenic urticaria that occurs upon contact with water). Others can be due to substances that get in contact with the skin (common among patients with skin asthma), intake of drugs (captopril, rifampicin, ciprofloxacin,vancomycin), some can be related to the food that a person eats (secondary to nutrients in those foods, spices, coloring agents or preservatives) or alcohol intake.
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