Urticaria factitia L50.30

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 11.04.2022

Synonym(s)

Dermographic urticaria; Dermographism; Dermographism of cholinergic; factitious urticaria; Skin writing urticaria; Symptomatic urticarial dermographism; Urticaria dermographic

Definition
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Most frequent physical urticaria with mostly linearly arranged wheals in the area of mechanically irritated skin areas, e.g. chafing spots of clothing.

Occurrence/Epidemiology
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Urticaria factitia, as well as urticarial dermographism, often occur together with other forms of urticaria. They not infrequently persist after the "accompanying urticaria" has subsided and are then perceived as the only "disease symptom".

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Etiopathogenesis
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Increased psychovegetative excitability, focus or medication (penicillin, acetylsalicylic acid). Not infrequently accompanying phenomena in parasitoses or insect bite reactions.

Clinical features
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Striped, highly itchy wheals of varying persistence and strength, accompanied by a broad reflex erythema that extends far beyond the actual area of exposure. Multiple scratching artifacts are often present.

Diagnosis
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Provocation test by firmly scratching the skin on the back or forearm in the form of lines (preferably using a wooden spatula). This provokes various reactions, which can be differentiated according to latency time, duration and itching (see table). The rare intermediate and late types can be preceded by a typical immediate reaction. In cholinergic urticarial dermographism numerous pinhead-sized wheals appear in a striped arrangement instead of a line-like wheal. Familial and cold-dependent urticarial dermographism are also rare.

Differential diagnosis
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Urticaria pigmentosa.

General therapy
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As a rule, no therapy is necessary. If necessary, avoid triggering factors (e.g. clothing that is too tight) or noxious substances (e.g. drugs such as aspirin, lidocaine, penicillin). Hardening measures (e.g. alternating shower, sauna). In the refractory phase induction of tolerance development. Psychosomatic counselling.

External therapy
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Symptomatically with antihistamine-containing gels such as dimetinden (e.g. Fenistil gel), clemastine (e.g. Tavegil gel), bamipine (e.g. Soventol gel). Usually rather moderate results.

Internal therapy
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In pronounced cases, the mast cell stabilizer ketotifen (e.g. zadites) shows good efficacy on wheals and itching. Initially 1 mg/day (once/day 1 Kps.) for 3-4 days, then increase to 2 times/day 1 mg and later to 2 times/day 2 mg p.o.
Non-sedating antihistamines such as desloratadine (Aerius) 5-10 mg/day, cetirizine (Zyrtec) 10 mg/day, levocetirizine (Xusal) 5-10 mg/day can also be used.
If necessary, use sedative medication at night: Hydroxycin (e.g. Atarax) 25-75 mg/day p.o. or Opipramol (e.g. Insidon) 50-150 mg/day p.o.
In case of resistance to therapy, an experiment with a pseudoallergen-free diet (no preservatives, colorants or antioxidants) over 4-6 weeks should be carried out, see also Urticaria, chronic.

Tables
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clinical picture/symptom	Latency	Duration	Itching
UDG	Two to ten minutes.	10-30 minutes.	-
UF	1-5 minutes.	20-30 minutes.	+++
UDG/UF intermediary type	30-120 minutes.	3-6 hours	-
UDG/UF delayed type	4-6 hours.	24-48 hrs.	-
Cholinergic Dermographism/UF	5-10 minutes.	20-30 minutes.	+/-

Note(s)
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A defined exertion of pressure can be triggered with a standardized dermographometer, the tip of which can be used to trigger a pressure of 10-160g/qmm (HTZ Limited, Vulcan Way, New Addington UK).

Literature
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Cap JP et al (1985) The effect of ketotifen in Urticaria factitia and Urticaria cholinergica in a crossed double-blind experiment. Dermatologist 36: 509-511
Butcher M, grave J (2004) Physical urticaria. dermatologist 55: 344-349
Kontou-Fili K et al (1997) Physical urticaria:classification and diagnostic guidelines. Allergy 552: 504-513
Juhlin L et al (1987) Inhibiting effect of cetirizine on histamine-induced and 48/80-induced wheals and flares, experimental dermographism and cold-induced urticaria. J Allergy Clin Immunol 80: 599-602
Termeer C et al (2015) Chronic spontaneous urticaria- A treatment path for diagnosis and therapy in the practice. JDDG 13: 419-429