Dermatographia

DERMATOGRAPHIA Shaza Ahsan MBBS II/II, D Y Patil School Of Medicine, Nerul, Navi Mumbai. April, 2017

Added by Shaza Ahsan on plexusmd.com | April, 2017 Dermatographia

Introduction

Dermatographic urticaria aka dermographism or "skin writing" is a skin disorder and one of the most common variety of urticaria.

Urticaria, also known as hives, weals, welts or nettle rash – is a raised, itchy rash that appears on the skin. The rash ranges in size from a few millimetres to the size of a hand.

Although the affected area may change in appearance within 24 hours, the rash usually settles within a few days. It can be triggered by many substances or situations and usually starts as an itchy patch of skin that turns into swollen red welts.

Doctors may refer to urticaria as either:

• Acute urticaria – The rash develops suddenly and clears completely within 24-48 hours. Most cases are self-limiting. • Chronic urticaria – In rare cases, the rash persists with recurrent episodes lasting for more than six weeks.

The majority of chronic urticarial cases have an idiopathic cause. In perhaps more than 50% of patients with chronic idiopathic urticaria, it is caused by an autoimmune reaction. The development of urticaria is often an isolated event without systemic reaction.

Dermatographic urticaria is marked by the appearance of weals or welts on the skin as a result of scratching or firm stroking of the skin. Seen in 4–5% of the population, it is one of the most common types of urticaria in which the skin becomes raised and inflamed when stroked, scratched, rubbed.

Added by Shaza Ahsan on plexusmd.com | April, 2017 Dermatographia

Clinical Features

Symptoms are thought to be the induced by release of inflammatory granules containing histamine from mast cells on the surface of the skin. Due to the lack of antigens, histamine causes the skin to swell in affected areas. If the membrane enclosing the mast cells is weak, it will easily and rapidly break down under physical pressure, which will therefore cause an allergic-like reaction. However, the exact underlying cause of dermographism is precisely not known.

Passive transfer of the dermographic response with Immunoglobulin E or Immunoglobulin M containing serum has been reported but no allergen has been identified.

Symptomatic dermographism may be triggered by drugs like penicillin, an insect bite, Helicobacter pylori infection, or an infestation (e.g., scabies, Fasciola hepatica).

Approximately 75% of patients with hyper eosinophilic syndrome, which has multisystem involvement and high mortality, have dermographism.

Psychologic factors and a history of stressful life events have been implicated as triggering factors in 30% of patients. However, a small prospective study showed no alteration in dermographic reaction following

Added by Shaza Ahsan on plexusmd.com | April, 2017 Dermatographia social stress provocation tests. Symptomatic dermographism may be a presenting feature of dermatomyositis.

Dermographism may occur in systemic mast cell proliferation i.e., mastocytosis. Congenital symptomatic dermographism has been described as the first sign of systemic mastocytosis.

Signs upon physical examination may be variable depending on when the patient presents to the clinic. At one extreme, the patient may be asymptomatic, while at the other extreme, the patient may have a generalized urticaria with extracutaneous symptoms. Signs and symptoms of dermatographia include raised red lines, swelling, inflammation, hive- like welts and itching. Symptoms can be aggravated by heat, minor pressure such as from scratching, tight or abrasive clothing, from rubbing with towels, exercise and physical & emotional stress.

In a normal case, the swelling will reduce itself with no treatment within 15–30 minutes, but, in extreme cases, itchy red weals may last anywhere from a few hours to days.

DARIER’S SIGN:

The skin changes produced by stroking the skin lesions in mastocytosis indicates a positive Darier’s sign. The area becomes raised and red.

Rarer forms of dermographism include the following

-Red dermographism: Repeated rubbing induces small, punctate wheals that are more prominent on the trunk than on the limbs. This form is possibly associated with seborrheic dermatitis.

-Follicular dermographism: Transitory, discrete, follicular, urticarial papules occur on a bright erythematous background.

-Cholinergic dermographism: A large erythematous line studded with punctate wheals similar to cholinergic urticaria (wheals smaller than classic urticaria and surrounded by large areas of macular erythema).

-Delayed dermographism: Approximately 3-8 hours after the immediate dermographic response, a deep, tender, burning wheal returns to the same

Added by Shaza Ahsan on plexusmd.com | April, 2017 Dermatographia site and persists for up to 48 hours. This form is recalcitrant to conventional therapy and is closely related to pressure urticaria.

-Exercise induced dermographism.

Management and Treatment

Patients need to be well versed in the nature of their urticarial reaction for prevention techniques, and in suitable alternatives.

Affected individuals should avoid foods and food products that trigger their symptoms. One should be aware that food extracts are sometimes used in cosmetics, which may lead to unintended exposure. Advice regarding the avoidance of cross-reactive foods should be given after appropriate skin prick testing or a RAST because not all individuals are affected in this way. Dermographism can be treated by antihistamines. These may need to be given as a combination of H1 antagonists, or possibly with an H2- receptor antagonist such as cimetidine. Not taking hot baths or showers may help if it is generalized and possibly for localized (in a specific area). If not taking showers helps, it may be a condition called shower eczema. If it affects mainly the head, it may be psoriasis. In rare cases, allergy tests may uncover substances the patient is allergic to.

While chromoglycate, a mast cell stabilizer, is used topically in rhinitis and asthma, it is not effective orally for treating chronic urticaria .Acupuncture and Chinese herbs have long been used to treat urticaria in the Asian world.

In some patients with dermatographia, the condition subsides on its own.

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References

1) Dinc A, Karaayvaz M, Caliskaner AZ, Pay S, Erdem H, Turan M. Dermographism and atopy in patients with Behcet’s disease. J Investig Allergol Clin Immunol. Nov-Dec 2000;10(6):368-71.

2) Martorell A, Sanz J, Ortiz M, Julve N, Cerda JC, Ferriols E. Prevalence of dermographism in children. J Investig Allergol Clin Immunol. May-Jun 2000;10(3):166-9.

3) Lambiris A, Greaves MW. Dyspareunia and vulvodynia: unrecognised manifestations of symptomatic dermographism. Lancet. Jan 4 1997;349(9044):28.

4) www.wikipaedia.org

5) allergycliniconline.com/

6) Wozel G, Sahre EM, Barth J (1990). "[Effectiveness of combination treatment with H1-(Tavegyl) and H2-antagonists (Altramet) in chronic/chronically-recurrent urticaria]". Dermatologische Monatsschrift (in German) 176 (11): 653–659. ISSN 0011- 9083.OCLC 1566270. PMID 2083605.

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About the Author

Shaza Ahsan

2nd Year MBBS Student, Dr. D Y Patil Medical College,Navi Mumbai.

PlexusMD, Management Intern

Her topics of interests include dermatology, forensic medicine, psychology & cardiovascular medicine.

Connect at: www.plexusmd.com/missShazaAhsan

Reviewed by PlexusMD Editorial Panel

Added by Shaza Ahsan on plexusmd.com | April, 2017 Dermatographia

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