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Man, 39 year old Itching for 3 hours after dinner What is lesion? What is your diagnosis?

Man, 39 year old Itching for 3 hours after dinner What is lesion? What is your diagnosis?. Case 1. Urticaria 荨麻疹. Danqi Deng Ph.D Prof Dept. of Dermatology, The Second Affiliated Hospital of Kunming Medical University. Outline. 1.What is urticaria ? Definition（定义）

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Man, 39 year old Itching for 3 hours after dinner What is lesion? What is your diagnosis?

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  1. Man, 39 year old Itching for 3 hours after dinner What is lesion? What is your diagnosis? Case 1

  2. Urticaria荨麻疹 Danqi Deng Ph.D Prof Dept. of Dermatology, The Second Affiliated Hospital of Kunming Medical University

  3. Outline 1.What is urticaria ? Definition（定义） 2.Who gets urticaria? Frequency（发病情况） 3.What causes urticaria? Etiology（病因 ) 4.How does urticaria develop? Pathogenesis（发病机理）

  4. Outline • 5.What does urticaria display? • Clinical features（临床表现） • 6.How do you make sure urticaria? • Diagnosis(诊断） • 6.How is urticaria treated ? • Treatment（治疗） urtica

  5. Definition 定义 Urticaria, is the most frequent dermatologic disorder with wheals(风团) that is very pruritic(瘙痒). It appears as raised, well-circumscribed areas of erythema and edema involving the dermis(真皮) and epidermis(表皮) Urticaria is not a single disease but a reaction pattern that represents cutaneous mast cell degranulation, resulting in extravasation(外渗） of plasma into the dermis.

  6. Frequency 发病情况 • Acute urticaria (荨麻疹）affects 15-20% of the general population at some time during their lifetime. • Incidence rates for acute urticaria are similar for men and women. • Chronic urticaria occurs more frequently in women (60%).

  7. Etiology病因 Infections Foods Etiology Drugs SLE, rheumatoid arthritis(类风湿） Disease Environmental factors Emotional stress 7 7

  8. Etiology病因 Foods shellfish fish, eggs, cheese, chocolate, nuts, berries, tomatoes

  9. Etiology病因 Drugpenicillins（青霉素） sulfonamides（磺胺）salicylates（水杨酸盐） NSAIDs（非激素抗炎药） codeine（可待因）

  10. Etiology病因 Bacteria 细菌 Virus病毒 Fungi 真菌

  11. Etiology病因 Cold Heat Sun Environmental factors

  12. Etiology病因 • Animals Insect（昆虫） Furs (毛皮）

  13. Etiology病因 • Plants • Pollens （花粉）

  14. Etiology病因 Emotional stress Exercise

  15. Pathogenesis 发病机制 Pathogenesis Allergy Non allergy Some food Toxin 毒素 Some drugs I type III type II type

  16. Pathogenesis 发病机制

  17. Pathogenesis 发病机制

  18. Pathogenesis 发病机制

  19. Pathogenesis 发病机制 激活 MC 渗出 血管扩张 募集 IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, TNFa, MIPs, IFNg, GM-CSF, TGFb, bFGF, VPF/VEGF, PGD2, LTB4, LTC4, PAF, 组胺 5-羟色胺, 肝素, 硫酸软骨素, 糜蛋白酶, 纤维蛋白溶酶, 组织蛋白酶 G Courtesy of Prof. M. Maurer.

  20. Pathogenesis 发病机制 ？？？ 速发相 迟发相 CellsMediatorsSymptoms Step 2Early PhaseMinutes Time Step 3Late PhaseHours Step 1Sensitization Itype发生机制 1. American Academy of Allergy, Asthma & Immunology. The Allergy Report. 2000.

  21. Pathogenesis 发病机制 Mediators and dytokines Cytokines Chemokines PAF Chymase 糜蛋白酶 LTC4 Mast Cell Late Phase发生和发展 (J Allergy Clin Immunol,2000;105:847-59)

  22. Pathogenesis 发病机制 Allergen (eg, pollen, domestic mite, fungi) Dendritic cell(antigen-presenting cell) T cell TH1 cell(T helper cell, type 1) TH2 cell(T helper cell, type 2) `B cells IFN- IL-4IL-13 Proliferation/differentiation Activated B cells(IgE synthesis & release) IgE antibodies 2. Naclerio RM. N Engl J Med. 1991;325:860-869.

  23. Clinical manifestation 临床表现 • Chronic urticaria is reported to be more common in adults, while acute urticaria is more common in children • Atopic dermtitis(特应性皮炎） patients are more common suffer from urticaria. • acute urticaria 急性荨麻疹 • chronic urticaria 慢性荨麻疹 • Other Variants of Urticaria 特殊类型荨麻疹

  24. Clinical manifestation 临床表现 • Acute urticaria • Primary lesion: wheal and surrounding erythema（红斑）(flare). • Distribution of lesions: Lesions can be localized or generalized. • Color of lesions: Depending on background skin color, lesions may be pale（灰白色）to red. • An individual wheal typically lasts for less than 24 hours. • Pruritus（瘙痒） is the most common associated symptom.

  25. Clinical manifestation 临床表现

  26. Clinical manifestation临床表现

  27. Clinical manifestation临床表现 • Clinical manifestation except skin of acute urticaria • Anaphylactic shock 过敏性休克 • Digestive system signs or symptoms消化系统症状 • Lungs for pneumonia or asthma呼吸道表现 • The presence of systemic signs or symptoms（全身症状），particularly fever, arthralgias.（关节痛）

  28. Clinical manifestation临床表现 Chronic urticaria defined as urticaria that persists for longer than 6 weeks. The cause of chronic urticaria often is undetermined

  29. Other Variants of Urticaria特殊类型荨麻疹 • Dermographism 皮肤划痕症（人工荨麻疹） • Cold Urticaria 寒冷性荨麻疹 • Cholinergic urticaria 胆碱能性荨麻疹 • Solar Urticaria 日光性荨麻疹 • Pressure urticaria 压力性荨麻疹

  30. Clinical manifestation临床表现 • Dermographism 皮肤划痕症urticarial lesions resulting from light scratching

  31. Clinical manifestation临床表现 • Cold urticaria • Genetic (家族性)，为常染色体显性遗传 • Accquired(获得性)，较常见

  32. Clinical manifestation临床表现 • 冷激发试验Application of an ice cube to the skin may test for cold urticaria.

  33. Clinical manifestation临床表现 • Cholinergic urticaria胆碱能性荨麻疹 • More common in young. • Heat, exercise, or stress

  34. Clinical manifestation临床表现 • Small wheal • Short time

  35. Clinical manifestation 临床表现 Cholinergic urticaria After exercise Before exercise

  36. Clinical manifestation 临床表现 • Solar urticaria日光性荨麻疹 • Sun exposure • Most is UVB (300nm )

  37. Clinical manifestation 临床表现 • Pressure urticaria 压力性荨麻疹 • After 2-6 hours pressure • Edema of local skin • The lesion persists for 8-72 hours. • Heel and hip

  38. Clinical manifestation 临床表现 • Angioedema血管性水肿 • Acquired angioedema : • the lips, tongue, testicles（睾丸）or larynx(喉） • Hereditary (遗传性) angioedema: is characterized by recurrent attacks of angioedema (without urticaria) involving the skin, GI tract, respiratory(呼吸) tract, and mucous membranes in a patient with a positive family history. • The disorder is autosomal (常染色体)dominant, and it is caused by a functional deficiency of the C1 inhibitor protein.

  39. Clinical manifestation 临床表现 Edema: the lips, tongue, testicles（睾丸）or larynx(喉）

  40. Clinical manifestation 临床表现

  41. Diagnosis 诊 断 • Lesion:Wheal • Transient(片刻） nature • Itching

  42. Differential diagnosis鉴别诊断 • Popular Urticaria 丘疹性荨麻疹 • pruritic papules (丘疹)and papulovesicles(丘疱疹). • The lesions tend to be grouped on exposed areas,particularly the extensor surfaces of the extremities(四肢). • Urticarial vasculitis 荨麻疹性血管炎 • Individual urticarial lesions that are painful, long lasting (longer than 36-48 h) • Urticarial lesions that leave residual hyperpigmentation or ecchymosis(紫癜)upon resolution • Arthralgias, arthritis, weight changes, bone pain, or lymphadenopathy

  43. Laboratory Studies实验室检查 Skin prick testing Full blood count Urinalysis ESR Cryoglobulins Thyroid function and autoantibodies Parasitology Challenges Skin biopsy Autologous serum skin test Complement studies Edoscopy

  44. 荨麻疹的诊断指南 Wheal 风团 Angioedema 血管性水肿 >24 小时? 有风团? 是 否 是 否 活检: 血管炎? >6 周? 否 是 否 询问病史/ 体检 询问病史/ 体检: 与压迫相关吗? 是 是 否 荨麻疹性 血管炎 物理性荨麻疹 其它荨麻疹 慢性荨麻疹 急性荨麻疹 压迫性荨麻疹 遗传性，获得性血管性水肿, 或慢性荨麻疹 HAE = hereditary angioedema; AAE = acquired angioedema. Reproduced with permission from Zuberbier et al. Allergy. 2005. In press.

  45. Treatment治疗 1.Found out the causes 2.Avoidance of some factors such as mentalstress,overtiredness, alcohol,nonsteroidal anti-inflammatory drugs(NSAID) isrecommended. 3. Medical Care

  46. Treatment治疗 • Nonsedating anti-H1 antihistamines (抗组胺药)remain the mainstay of treatment. • Vit C and Calcium(钙剂) Application of lotions withmenthol and phenol provide prompt relief of pruritus for some patients.such as Albe lotion.

  47. Treatment治疗

  48. Treatment治疗 Antihistaminics loratadine氯雷他定（10mg），oral，10mg Qd cetirizine西替利嗪（10mg），oral，10mg Q d fexofenadine非索非那定（30mg），oral，，60 Bid levocetirizine左西替利嗪（50mg），oral，10mg Qd

  49. Treatment治疗 Antihistaminics Pregnancy（妊娠） Cetirizine(西替利嗪)and loratadine (氯雷他定)are category B; A first-generation antihistamine, such as chlorpheniramine(马来酸氯笨那敏）, may be considered the drug of choice .

  50. Treatment治疗 H2 antihistamines, such as cimetidine（西米替丁） famotidine（法莫替丁），ranitidine（雷尼替丁） Antileukotrienes（抗白三烯）： Montelukast （孟鲁斯特钠）at 10 mg/d may be particularly helpful for patients due to aspirin or other nonsteroidal anti-inflammatory drugs. Montelukast（孟鲁斯特钠） is approved for perennial allergic rhinitis in children aged 6 months and older.

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