Contact urticaria (CU) is a hypersensitivity reaction, precipitated by dermal or mucosal contact with a trigger (urticariogen). Typically, only the area of the skin directly exposed to the urticariogen will display the symptoms commonly known as "wheal and flare reaction": edematous lesions (wheals) surrounded by erythema, usually with itching or burning sensation [1] [2] [3]. However, eczema covering the affected area might mask the symptoms and lead to under diagnoses. The main characteristic of CU is the rapid onset of symptoms, sometimes within minutes of contact with the inducing agent. After several hours (up to a day) symptoms regress spontaneously, leaving no residual effects. Depending on the time between the symptom flare-up and the physical examination, the patient may appear to be asymptomatic [1] [4].

The severity and distribution of symptoms may depend on etiology of CU. While non-immunologic CU (NICU) is usually limited to the exposed skin, some patients with immunologic CU (ICU) may develop generalized urticaria, rhino-ocular, respiratory, laryngeal or gastrointestinal symptoms and, in most severe cases, anaphylactic shock. Extracutaneous manifestations of CU are referred to as contact urticaria syndrome (CUS) [3] [5].

First exposure to an urticariogen can lead to NICU, whereas in ICU first contact results in sensitization with symptoms developing only on subsequent exposure [3]. Hence, patients may or may not associate a specific substance to the onset of CU.

• Swelling

  The severity of redness and swelling can range from slight redness or spots with minimal swelling to fiery redness with tense swelling and weals. Rash usually resolves by itself within 24 hours of onset. [dermnetnz.org]

  Other symptoms include swelling of hand when holding cold objects, lip swelling when eating a cold food, as well as generalized symptoms of headache, flushing, abdominal pain, and fainting in areas that are largely affected. [medigest.uk]

  In general, angioedema lasts longer than urticaria, but the swelling usually goes away within 24 hours. Symptoms include deep swelling around the eyes and lips, and sometimes swelling of the genitals, hands, and feet. [my.clevelandclinic.org]

  If the cause of any oral symptoms is less clear and the symptoms persist it is worth referring to a dermatologist to rule out other causes such as a contact allergic dermatitis to toothpaste or amalgam in fillings (the latter can cause facial swelling [pcds.org.uk]

• Pain

  Angioedema can also affect the gut, and here it can lead to symptoms such as severe abdominal pain. Angioedema is treated with oral antihistamines such as loratadine. [medic8.com]

  When to See Your Doctor Call your doctor if your rash is painful or worries you, or if it isn't better after a couple of days. Your doctor will take a look and ask you questions to help figure out what's going on. [webmd.com]

  Contact dermatitis symptoms can range from mild redness and dryness to severe pain and peeling that can be disabling. [my.clevelandclinic.org]

  […] hives should be suspected if episodes are rare, short-lived and occur under specific circumstances, for example: Only when exercising Always within 1-2 hours of a meal When symptoms involving other organs occur around the same time, such as stomach pain [rch.org.au]

  Other symptoms include swelling of hand when holding cold objects, lip swelling when eating a cold food, as well as generalized symptoms of headache, flushing, abdominal pain, and fainting in areas that are largely affected. [medigest.uk]

• Surgical Procedure

  Latex sensitivity in surgical patients Spina bifida patients are at increased risk of latex sensitization because of early exposure to latex and the number of surgical procedures to which they are exposed. [emedicine.medscape.com]

  Of note, spina bifida patients are at increased risk of latex sensitization because of early exposure to latex in the number of surgical procedures they endure. What is the Cause of the Disease? Etiology Proteins and also chemicals are involved. [dermatologyadvisor.com]

• Malaise

  Immediately, she developed oralaryngeal malaise and pruritic rash. Nasal obstruction and increase of cutaneous lesions were seen although she took betamethasone, 2 mg, orally. [scirp.org]

  He presented secondary generalized hives with malaise and experienced pharyngeal discomfort on drinking cold beverages. [medicaljournals.se]

• Hoarseness

  Features of extracutaneous reactions include: Wheezing (bronchial asthma) A runny nose, watery eyes Lip swelling, hoarse throat, difficulty swallowing Nausea, vomiting, diarrhoea, cramps Severe anaphylactic shock (this can be life-threatening) Contact [dermnetnz.org]

  […] oral steroids, food diary, elimination diet, allergy (prick) tests fluid under epidermis (raised flat lesion), but nothing going on in epidermis (normal appearance) Symptoms associated with urticaria (underlying condition, more severe allergic rxn) hoarseness [quizlet.com]

  Patients presenting stage 3 of contact urticaria syndrome may present symptoms of bronchial asthma (dyspnea, wheezing), angioedema, rhinitis, conjunctivitis (running nose, watery eyes), oropharyngeal symptoms (e.g. lip swelling, hoarseness, difficulty [ncbi.nlm.nih.gov]

• Respiratory Distress

  […] vasculitis nuclear dust (PMNs) attaching blood vessels in epidermis (bx) urticaria leads to a chain of events: angioedema, respiratory distress, CV crisis deeper dermal and subQ tissues, swelling +/- pruritis, involves areas w/ loose CT (eyelids, lips [quizlet.com]

  Some people have urticaria that is complicated by angio-oedema, a swelling of the deeper dermis and tissues (e.g., mucosal surfaces), with laryngeal oedema potentially causing respiratory distress and death. [3] Zuberbier T, Aberer W, Asero R, et al. [bestpractice.bmj.com]

  distress when inhaling smoke from grilled fish 139, and a case of rhinitis, choking and systemic urticaria (syndrome) following the ingestion of egg in a patient who treated her hair weekly with a homemade egg‐white based mask 147. [onlinelibrary.wiley.com]

• Vomiting

  […] nor rashes/swellings commencing several hours after ingestion of food urticaria due to IgE-mediated food allergic reactions seldom occur in isolation i.e. additional symptoms are usually present such as oropharyngeal itching and discomfort, wheezing, vomiting [gpnotebook.co.uk]

  Other symptoms can include nausea, vomiting, abdominal pain, and more. [allure.com]

  Features of extracutaneous reactions include: Wheezing (bronchial asthma) A runny nose, watery eyes Lip swelling, hoarse throat, difficulty swallowing Nausea, vomiting, diarrhoea, cramps Severe anaphylactic shock (this can be life-threatening) Contact [dermnetnz.org]

  […] allergic to something you also have a high temperature and feel generally unwell you also have swelling under the skin – this might be angioedema Go to A&E or call 999 if you have: difficulty breathing difficulty swallowing dizziness or fainting nausea or vomiting [nhs.uk]

• Abdominal Pain

  Other symptoms include swelling of hand when holding cold objects, lip swelling when eating a cold food, as well as generalized symptoms of headache, flushing, abdominal pain, and fainting in areas that are largely affected. [medigest.uk]

  These include: abdominal pain nausea vomiting diarrhea hypersalivation CU can also be accompanied by exercise-induced anaphylaxis, a more severe allergic reaction to exercise. [healthline.com]

  pain Reference: (1) Powell RJ et al; British Society for Allergy and Clinical Immunology (BSACI). [gpnotebook.co.uk]

  Other symptoms can include nausea, vomiting, abdominal pain, and more. [allure.com]

  pain, arthralgia, hematuria, flushing, headache, syncope, hypotension, shock 24-72 hrs, pertechiae and purpura, ecchymoses (bruising) w/ resolve, dx w/ a skin bx (5-10% pts w/ urticaria) Histology of urticarial vasculitis nuclear dust (PMNs) attaching [quizlet.com]

• Lip Swelling

  Other symptoms include swelling of hand when holding cold objects, lip swelling when eating a cold food, as well as generalized symptoms of headache, flushing, abdominal pain, and fainting in areas that are largely affected. [medigest.uk]

  Features of extracutaneous reactions include: Wheezing (bronchial asthma) A runny nose, watery eyes Lip swelling, hoarse throat, difficulty swallowing Nausea, vomiting, diarrhoea, cramps Severe anaphylactic shock (this can be life-threatening) Contact [dermnetnz.org]

  (An interesting case report of a patient presenting with lip swelling following the use of mouthwash. [dermatologyadvisor.com]

  She then developed new symptoms of lip swelling and truncal rash immediately after eating biscuits or bread containing oatmeal. Enzyme-linked immunosorbent assay (ELISA) testing revealed reactivity to an oat extract in the moisturizer. [ijdvl.com]

• Heart Disease

  […] cell histamine release) causal relationship is evident (ate food, stung, meds), immediate rxn newwheal/flare lesions appear indefinitely >/= 6 wks (50%>yr); impacts quality of life (mobility, clothing, gardening, employment) and is compared w/ ischemic heart [quizlet.com]

• Eczema

  OBJECTIVES: To identify factors associated with job change in a cohort of participants with recognised occupational hand eczema/contact urticaria METHODS: A registry-based study including 2703 employees with recognised occupational hand eczema/contact [ncbi.nlm.nih.gov]

  Other types of eczema include: atopic eczema (also called atopic dermatitis) – the most common type of eczema; it often runs in families and is linked to other conditions, such as asthma and hay fever discoid eczema – circular or oval patches of eczema [nhs.uk]

  However, although the clinical picture and biopsy findings are consistent with eczema, patch testing is generally negative. [escholarship.org]

  There was no sign of eczema, nor a history of skin diseases or atopy in the patient or her family. [jamanetwork.com]

• Blister

  (vesicles); poison ivy/oak is the most frequent cause of contact dermatitis in the US (50% of adult population is sensitive) Histology of contact dermatitis abnormal stratum corneum (not a basket weave), irregular epidermis, fluid/ blister formation, [quizlet.com]

  Pompholyx eczema (dyshidrotic eczema) — in which there are itchy clusters of blisters along the sides of the fingers and on the palms, often triggered by sweating. [dermnetnz.org]

  In both cases, your skin may blister, or you may get a raised red rash. Your skin will itch and maybe burn. When something is irritating or damaging your skin, you'll probably see a rash right away. [webmd.com]

  Irritant contact dermatitis symptoms include: Mild swelling of skin Stiff, tight feeling skin Dry, cracking skin Blisters Painful ulcers on the skin Symptoms vary depending on the cause of dermatitis. [my.clevelandclinic.org]

• Dermatographia

  Dermatographia, dermographism, or autographism describes welts or wheels produced by scratching or firmly stroking the skin. According to some dermatologists, dermographism is the most common form of physical urticaria. [rarediseases.org]

  It is also called dermatographism, dermatographia and dermatographic urticaria. [dermnetnz.org]

  Other causes include: infections, including viruses exercise anxiety or stress sun exposure exposure to cold, such as cold water or snow contact with chemicals scratching (dermatographia) putting pressure on the skin, such as from sitting too long or [kidshealth.org]

  Pressure Urticaria –Pressure urticaria is a form of hives and wheals that develop in response to physical pressure (similar to dermatographia). [cholinergicurticaria.net]

• Flushing

  Other symptoms include swelling of hand when holding cold objects, lip swelling when eating a cold food, as well as generalized symptoms of headache, flushing, abdominal pain, and fainting in areas that are largely affected. [medigest.uk]

  Common reactions may include small pinpoint hives, itching, wheals, flushing, and swelling. This differs from general hives reactions, which may occur spontaneously with no connection to a known physical stimulus. [cholinergicurticaria.net]

  […] raised flat lesion), but nothing going on in epidermis (normal appearance) Symptoms associated with urticaria (underlying condition, more severe allergic rxn) hoarseness, respiratory distress, vomiting, diarrhea, abdominal pain, arthralgia, hematuria, flushing [quizlet.com]

  Irritant contact dermatitis is usually treated with the following: Chemical burns are usually flushed with water followed by the use of antidote or specific remedy against the particular toxic chemical. [dermnetnz.org]

  Avoidance of these foods will help reduce itch and flushing (Berlin Diet). See Below: Foods with high Vaso-active amine (histamine) content: Dark Fish Mackerel, Tuna, Smoked Salmon, Sardines, Snoek. [allergyclinic.co.za]

• Purpura

  Symptoms associated with urticaria (underlying condition, more severe allergic rxn) hoarseness, respiratory distress, vomiting, diarrhea, abdominal pain, arthralgia, hematuria, flushing, headache, syncope, hypotension, shock 24-72 hrs, pertechiae and purpura [quizlet.com]

  These are often associated as well with other symptoms such as Raynaud’s phenomenon (a change in color for the fingers or other extremities) or purpura. [healthguidance.org]

  EM is: Usually not itchy Does not move around - individual lesions perist for days Has target lesions with a central papuler, blister, purpura or ulcer. [rch.org.au]

  Likewise, classic urticarial vasculitis is distinguished by individual wheals that last for more than 24 hours, are painful, and leave residual hyperpigmentation or purpura 12 ( Figures 7 and 8 ). [aafp.org]

• Suggestibility

  Our interpretation suggests that no reports of Type I reactions presented in the literature fulfill the criteria for immunologic contact urticaria. [ncbi.nlm.nih.gov]

• Hematuria

  […] epidermis (raised flat lesion), but nothing going on in epidermis (normal appearance) Symptoms associated with urticaria (underlying condition, more severe allergic rxn) hoarseness, respiratory distress, vomiting, diarrhea, abdominal pain, arthralgia, hematuria [quizlet.com]

• Tingling

  Someone who has urticaria may suffer itching, tingling or burning sensations at the site of the rash. [hse.gov.uk]

  […] non-immunological eg nettle rash, and immunological eg food, latex, plants or animal hair / fur History Latex allergy - refer to the related chapter on Contact allergic dermatitis (including latex and rubber allergy) Other contact eg food - symptoms include a tingling [pcds.org.uk]

  Signs and symptoms of affected skin areas include: Local burning sensation, tingling or itching Localised or generalised red swellings or weals may occur, especially on the hands. [dermnetnz.org]

  Skin lesions include wheal and flare reactions as well as symptoms such as itching, tingling or burning. Wheals appear as the unique symptom in contact urticaria, and eczema can be the only symptom in PCD. [dermatologyadvisor.com]

• Burning Sensation

  Someone who has urticaria may suffer itching, tingling or burning sensations at the site of the rash. [hse.gov.uk]

  Typically, only the area of the skin directly exposed to the urticariogen will display the symptoms commonly known as "wheal and flare reaction": edematous lesions (wheals) surrounded by erythema, usually with itching or burning sensation. [symptoma.com]

  Burning sensation can be one prominent feature. Swelling is contained to body parts that have come in contact with cold stimulus. Symptoms become worse when the exposed region is warmed. [medigest.uk]

  Signs and symptoms of affected skin areas include: Local burning sensation, tingling or itching Localised or generalised red swellings or weals may occur, especially on the hands. [dermnetnz.org]

• Stroke

  In 25–50% of normal people firm stroking of the skin produces first a white line, then a red line, then slight swelling down the line of the stroke, and a mild red flare in the surrounding skin. [dermnetnz.org]

  […] areas w/ loose CT (eyelids, lips), may occur w/ or w/o urticaria absolute/fx deficiency of inhibitor of the first complement component C1 esterase inhibitor or excessive consumption of C4 (2% of angioedema) linear wheal w/ flare at site where skin is stroked [quizlet.com]

  Dermatographia, dermographism, or autographism describes welts or wheels produced by scratching or firmly stroking the skin. According to some dermatologists, dermographism is the most common form of physical urticaria. [rarediseases.org]

  It can be diagnosed by observing the skin after stroking it with a tongue depressor or fingernail are more quantitatively employing a dermographometer where the level of stimulus can be controlled. [worldallergy.org]

Diagnosing CU starts with a detailed anamnesis, trying to identify the eliciting substance, followed by a physical examination. The next step involves cutaneous provocation tests, if necessary. Serology is rarely warranted and can be of use only in ICU.

Anamnesis

Given the variety of potential urticariogens, from cosmetics and foodstuffs to consumer goods (clothing, shoes, items containing latex), metals and industrial chemicals, virtually any substance can be suspected of precipitating CU [1] [6] [7]. Since occupational exposure is common, information about patients' workplace is highly relevant [3] [5]. Patient history includes the frequency, duration, severity and sites of urticaria occurrence in addition to personal and family history of atopy [1]. Use of antihistamines two days prior to cutaneous provocation tests should be excluded, to prevent false negative results [3].

Cutaneous provocation tests

Cutaneous tests compare the skin reaction upon contact with suspected urticariogens to positive and negative controls (e.g. saline and histamine hydrochloride, respectively) [1] [3]. Substances are conventionally applied to unaffected or slightly affected skin. Usually, treated areas are inspected periodically during an hour, starting at 15 minutes after application; wheals, edema or erythema denote a positive reaction. Due to variable sensitivity, various sites may be tested (forearm, upper arm, upper back), commonly starting with the one reported in patient history [1] [3] [8].

Initially, open application test is performed, by spreading each tested substance over a small, defined area [1] [3] [8]. In case of negative results, prick test can be used, where the skin is slightly pierced by a lancet subsequent to trigger-substance application [1] [3]. For non-standardized substances, scratch and chamber-scratch tests are the methods of choice [1] [3]. Use test is convenient for reactions triggered by consumer goods [3]. The possibility of anaphylaxis warrants caution in provocation tests [1].

Serology

Although not routinely used, radioallergosorbent test (RAST) for allergen-specific IgE antibodies may confirm the diagnosis of ICU [9].

At this dose, 19 of 20 (95%) patients responded to treatment, with 12 of 20 (60%) becoming symptom free. Only one patient was refractory to treatment. [ncbi.nlm.nih.gov]

Following the placebo-controlled double-blind phase patients will enter the open-label phase and receive rilonacept open-label treatment (160mg or 320mg depending on treatment response during part A). [clinicaltrials.gov]

The prognosis varies widely. The diagnosis of immunological CU is based on the clinical history and on a positive prick test with the suspected substance and/or measurement of specific IgE. © 2016 John Wiley & Sons A/S. [ncbi.nlm.nih.gov]

The prognosis is completely dependent on the patient’s ability to avoid contact with the substance. The therapeutic options discussed above are only employed if prevention has failed and symptomatic relief is necessary. [dermatologyadvisor.com]

"Analysis of Primary Treatment and Prognosis of Spontaneous Urticaria." Allergology International 66 (2017): 458-462. [medicinenet.com]

[…] ate food, stung, meds), immediate rxn newwheal/flare lesions appear indefinitely >/= 6 wks (50%>yr); impacts quality of life (mobility, clothing, gardening, employment) and is compared w/ ischemic heart disease Acute: anti-histamines (H1), determine etiology [quizlet.com]

The etiology of contact urticaria can be nonimmunologic or immunologic. Common inducers of nonimmunologic contact urticaria are plants, animals, and direct histamine liberators e.g., spices, fragrances, or drugs. [link.springer.com]

The severity and distribution of symptoms may depend on etiology of CU. [symptoma.com]

Etiology, classification, and treatment of urticaria. Cutis. 2007 Jan;79(1):41-9. http://www.ncbi.nlm.nih.gov/pubmed/17330621?tool=bestpractice.com It is a mast cell driven disease. [bestpractice.bmj.com]

The etiology of different forms of urticaria in childhood. Pediatr Dermatol. 2004;21(2):102–108. 9. [aafp.org]

The book discusses its definition, history, epidemiology, and occupational relevance. [bokus.com]

This article reviews the pathophysiology and different clinical manifestations of contact urticaria and its association with cosmetics and toiletries. [mdedge.com]

A better understanding of the pathophysiological mechanisms of FCHS and food allergy in general is essential for deeper insights and future emergence of effective therapies. [ncbi.nlm.nih.gov]

The aim of this book is to describe in detail the latest understanding of the pathophysiological mechanisms involved in the three main aspects of contact dermatitis (irritation, allergy and urticaria), to then encapsulate modern approaches to the evaluation [amazon.com]

Some pre-work creams may help to prevent the development of dermatitis, but they are not generally effective as a preventative measure [ 6 ], although they may improve skin condition when used in combination with cleansing and after-work creams. [academic.oup.com]

In secondary prevention, when even low-allergen non-powdered gloves are not tolerated, latex free gloves should be used." [Kanerva 2004, p. 101] See "Latex Allergy: A Prevention Guide" at the NIOSH web site. [haz-map.com]

Our results show the effectiveness of this preventive measure, and suggest that this practice should be extended to other sectors. © 2015 British Association of Dermatologists. [ncbi.nlm.nih.gov]

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2. Poonawalla T, Kelly B. Urticaria. American Journal of Clinical Dermatology. 2009;10(1):9-21.
3. Maibach H, Bhatia R, Alikhan A. Contact urticaria : Present scenario. Indian Journal of Dermatology. 2009;54(3):264.
4. Wakelin SH. Contact urticaria. Clinical and Experimental Dermatology. 2001;26(2):132-136.
5. Williams J, Lee A, Matheson M, Frowen K, Noonan A, Nixon R. Occupational contact urticaria: Australian data. British Journal of Dermatology. 2008;159(1):125-131.
6. Giménez-Arnau A, Silvestre JF, Mercader P, et al. Shoe contact dermatitis from dimethyl fumarate: clinical manifestations, patch test results, chemical analysis, and source of exposure. Contact Dermatitis. 2009;61(5):249-260.
7. Stingeni L, Neve D, Tondi V, Bacci M, Lisi P. Immunological contact urticaria caused by dimethyl fumarate. Contact Dermatitis. 2014;71(3):180-183.
8. Helaskoski E, Suojalehto H, Virtanen H, et al. Occupational asthma, rhinitis, and contact urticaria caused by oxidative hair dyes in hairdressers. Annals of Allergy, Asthma & Immunology. 2014;112(1):46-52.
9. Lernia VD, Albertini G, Bisighini G. Immunologic contact urticaria syndrome from raw rice. Contact Dermatitis. 1992;27(3):196-196.