Review of Dermatology Mina Saber MD Assistant Professor
Review of Dermatology Mina Saber, MD Assistant Professor of Dermatology
Common skin Disorders ØUrticaria and angioedema ØPruritus ØAcne vulgaris ØFingal disease ØWart
Common skin Disorders ØUrticaria and angioedema ØPruritus ØAcne vulgaris ØFingal disease ØWart
Urticaria and Angioedema Ø 15 -20% of population experience at least one episode of urticaria during lifetime ØAcute urticaria 6 w> vs chronic urticaria 6 w<
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • Idiopathic 50% • Upper respiratory tract infection 40% • Drugs 9% • Foods 1%
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticaria Cold contact urticaria Cholinergic urticaria
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • Dermographism • ~ 5% of normal papulation • No association with systemic disease, atopy food allergy or autoimmunity
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • Dermographism • Delayed pressure urticaria • • Deep erythematouse swellings at sites of sustained pressure to the skin Delay of 30 min to 12 h pruritic, painful or both May persist for several days
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • Dermographism • Delayed pressure urticarial • Cold contact urticaria • Most cases are idiopathic but may follow respiratory infection and bites • Itching, burning and whealing in cold-exposed area minutes after rewarming • Potential risk of anaphylaxis with cold bath and swimming
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • Dermographism • Delayed pressure urticarial • Cold contact urticarial • Cholinergic urticaria
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • Dermographism • Delayed pressure urticarial • Cold contact urticarial • Cholinergic urticarial • Multiple small paular wheals with obvious flare • Within 15 min of sweating inducing stimuli
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria • Vasculitis 5% • Ordinary 60% • Autoimmune pseudoallergic • Infection-related • idiopathic
Urticaria and Angioedema Ethiology Ø Common causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% Ø Cause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria • • • > 24 hours Painful and burning sensation as well as pruritus Residual purpura Often occur at pressure point Concurrent angioedema up to 40% Extra cutaneous manifestations (arthralgia, abdominal pain, COPD and …. ) • Vasculitis 5%
Urticaria and Angioedema Ethiology ØCommon causes of acute urticaria • • Idiopathic 50% Upper respiratory tract infection 40% Drugs 9% Foods 1% ØCause of chronic urticaria • Physical 35% • • Dermographism Delayed pressure urticarial Cold contact urticarial Cholinergic urticaria • Vasculitis 5% • Ordinary 60% • Autoimmune pseudoallergic • Infection-related • Idiopathic
Urticaria and Angioedema Clinical Presentation ØClinical presentation of wheal • Firm, edematouse plaque that is evanescent and pruritic • Generally last less than 24 hours
Urticaria and Angioedema Clinical Presentation ØClinical presentation of wheal • Firm, edematous plaque that is evanescent and pruritic • Generally last less than 24 hours ØAngioedema • Abrupt and short-lived swelling of the skin and mucouse membranes • In 50% of cases associated with urticaria
Urticaria and Angioedema Clinical Presentation ØClinical presentation of wheal • Firm, edematous plaque that is evanescent and pruritic • Generally last less than 24 hours ØAngioedema • Abrupt and short-lived swelling of the skin and mucous membranes • In 50% of cases associated with urticaria • Angioedema without wheal • Idiopathic (many cases) • Drug reaction (NSAIDs and ACE inhibitors) • C 1 inhibitor deficiency (inherited or acquired)
Urticaria and Angioedema Clinical Presentation ØClinical presentation of wheal • Firm, edematouse plaque that is evanescent and pruritic • Generally last less than 24 hours ØAngioedema • Abrupt and short-lived swelling of the skin and mucouse membranes • In 50% of cases associated with urticarial • Angioedema without wheal • Idiopathic (many cases) • Drug reaction (NSAIDs and ACE inhibitors) • C 1 inhibitor deficiency (inherited or acquired)
Urticaria vs Angioedema Urticaria
Urticaria vs Angioedema Urticaria Subcutaneous and submucosal surface Epidermis and dermis
Urticaria vs Angioedema Urticaria Subcutaneous and submucosal surface Last 48 -72 hours Epidermis and dermis Last < 24 hours
Urticaria vs Angioedema Urticaria Subcutaneous and submucosal surface Last 48 -72 hours Often accompanied with pain and tendernes Epidermis and dermis Last < 24 hours Associated with pruritus
Urticaria and Angioedema ØFor acute or episodic urticaria no investigations are required except where suggested by the history ØChronic urticaria refer to dermatologist
Urticaria and Angioedema Intervention ØGeneral measures • Stop nonspecific aggravating factors • • Overheating Stress Alcohol Drugs (aspirin and codein)
Urticaria and Angioedema Intervention ØGeneral measures • Stop nonspecific aggravating factors • • Overheating Stress Alcohol Drugs (aspirin and codein) • NSAIDs avoided in aspirin-sensitive patients with urticaria
Urticaria and Angioedema Intervention ØGeneral measures • Stop nonspecific aggravating factors • • Overheating Stress Alcohol Drugs (aspirin and codein) • NSAIDs avoided in aspirin-sensitive patients with urticaria • ACE inhibitors avoided in patients with angioedema without wheal and with caution in urticaria + angioedema
Urticaria and Angioedema Intervention ØGeneral measures • Stop nonspecific aggravating factors • • Overheating Stress Alcohol Drugs (aspirin and codein) • NSAIDs avoided in aspirin-sensitive patients with urticarial • ACE inhibitors avoided in patients with angioedema without wheal and with caution in urticaria + angioedema • Estrogen avoided in hereditary angioedema
Urticaria and Angioedema Intervention ØGeneral measures ØTopical treatments • Topical steroids (poor evidence) • Cooling antipruritic lotions • Calamine • Menthol 1%
Urticaria and Angioedema Intervention ØGeneral measures ØTopical treatments • Topical steroids (poor evidence) • Cooling antipruritic lotions • Calamine • Menthol 1%
Urticaria and Angioedema Intervention ØGeneral measures ØTopical treatments • Topical steroids (poor evidence) • Cooling antipruritic lotions • Calamine • Menthol 1%
Urticaria and Angioedema Intervention ØGeneral measures ØTopical treatments • Topical steroids (poor evidence) • Cooling antipruritic lotions • Calamine • Menthol 1%
Urticaria and Angioedema Pharmacological Agents (AHs) ØStage 1 ØAntihistamins (AH) • H 1 AHs are the first line treatment of all types of urticaria
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • H 1 AHs are the first line treatment of all types of urticaria • Peak serum concentrations in 1 -3 h
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • H 1 AHs are the first line treatment of all types of urticaria • Peak serum concentrations in 1 -3 h • 40% of patients response to AHs
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • H 1 AHs are the first line treatment of all types of urticaria • Peak serum concentrations in 1 -3 h • 40% of patients response to AHs • Hydroxyzine is the most potent of the classical AHs
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • • H 1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1 -3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Non-sedative AHs
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • • H 1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1 -3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Chlorpheniramine Cyproheptadine Hydroxyzine Ketotifen Promethazine Non-sedative AHs
Urticaria and Angioedema Pharmacological Agents ØAntihistamins (AH) • • H 1 AHs are the first line treatment of all types of urticaria Peak serum concentrations in 1 -3 h 40% of patients response to Ahs Hydroxyzine is the most potent of the classical AHs Sedative AHs Non-sedative AHs Chlorpheniramine Cyproheptadine Hydroxyzine Ketotifen promethazine Cetrizine Fexofenadine Loratadine Levocetrizine Desloratadine
Urticaria and Angioedema Pharmacological Agents (AHs) ØUse of classical AHs is limited by their side effects
Urticaria and Angioedema Pharmacological Agents (AHs) ØUse of classical AHs is limited by their side effects ØFirst line is non-sedating AHs
Urticaria and Angioedema Pharmacological Agents (AHs) ØUse of classical AHs is limited by their side effects ØFirst line is non-sedating AHs ØControl the symptoms but not influence the disease course
Urticaria and Angioedema Pharmacological Agents (AHs) ØUse of classical AHs is limited by their side effects ØFirst line is non-sedating AHs ØControl the symptoms but not influence the disease course ØIndividual response is variable
Urticaria and Angioedema Pharmacological Agents (AHs) ØUse of classical AHs is limited by their side effects ØFirst line is non-sedating AHs ØControl the symptoms but not influence the disease course ØIndividual response is variable ØIf one AH dose not work it is worth trying another
Urticaria and Angioedema Pharmacological Agents (AHs) ØIf little or no response ØIncrease above licensed dose and add sedating AH at night
Urticaria and Angioedema Pharmacological Agents (AHs) ØIf little or no response Øincrease above licensed dose and add sedating AH at night Recent international consensus
Urticaria and Angioedema Pharmacological Agents (AHs) ØIf little or no response Øincrease above licensed dose and add sedating AH at night Recent international consensus Increase the dose of second generation AHs up to 4 fold above license in adults when lower dose do not provide adequate symptom control
Urticaria and Angioedema Pharmacological Agents (AHs) ØStage 2
Urticaria and Angioedema Pharmacological Agents (AHs) ØStage 2 Add H 2 antagonist
Urticaria and Angioedema Pharmacological Agents (AHs) ØStage 2 Add H 2 antagonist ØEvidence is poor and not all authorities recommend this therapeutic approach
Urticaria and Angioedema Pharmacological Agents (AHs) ØStage 2 Add H 2 antagonist ØEvidence is poor and not all authorities recommend this therapeutic approach ØRanitidine is preferable
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone • 30 -50 mg/day Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone Targeted intervention • 30 -50 mg/day • Short time management of urticarial crisis and serious angioedema
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone Targeted intervention • 30 -50 mg/day • Short time management of urticarial crisis and serious angioedema • Avoid regular treatment
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone Targeted intervention • 30 -50 mg/day • Short time management of urticarial crisis and serious angioedema • Avoid regular treatment • Rebound is common problem
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØPrednosolone Targeted intervention • 30 -50 mg/day • Short time management of urticarial crisis and serious angioedema • Avoid regular treatment • Rebound is common problem • Long-term course of the urticaria is often not altered
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØEpinephrine Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØEpinephrine Targeted intervention • SC or IM for anaphylactic shock or severe anaphylactoid reactions
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØEpinephrine Targeted intervention • SC or IM for anaphylactic shock or severe anaphylactoid reactions • Angioedema of oropharynx and severe acute allergic urticaria
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØEpinephrine Targeted intervention • SC or IM for anaphylactic shock or severe anaphylactoid reactions • Angioedema of oropharynx and severe acute allergic urticaria • Not effective for hereditary angioedema
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØDoxepin Targeted intervention
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØDoxepin Targeted intervention • TCA with very potent H 1 and H 2 AH properties
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØDoxepin Targeted intervention • TCA with very potent H 1 and H 2 AH properties ØLeukoteriene inhibitors
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØDoxepin Targeted intervention • TCA with very potent H 1 and H 2 AH properties ØLeukoteriene inhibitors • Benefit in aspirin sensitive urticaria
Urticaria and Angioedema Pharmacological Agents (Combination Therapy) ØStage 3 ØDoxepin Targeted intervention • TCA with very potent H 1 and H 2 AH properties ØLeukoteriene inhibitors • Benefit in aspirin sensitive urticaria • Montelukast is usually chosen
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 4 specialist use only
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 5 ØImmunotherapy specialist use only
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 5 ØImmunotherapy ØPlasmapheresis Ø specialist use only
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 5 ØImmunotherapy ØPlasmapheresis ØIVIG infusion specialist use only
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 5 ØImmunotherapy ØPlasmapheresis ØIVIG infusion ØCyclosporine specialist use only
Urticaria and Angioedema Pharmacological Agents (Immunosuppresive) ØStage 5 ØImmunotherapy ØPlasmapheresis ØIVIG infusion ØCyclosporine ØOmalizumab specialist use only
Common skin Disorders ØUrticaria and angioedema ØPruritus ØAcne vulgaris ØFingal disease ØWart
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