The world of urticarial pathophysiology and dermal manifestations of allergy and urticaria has always fascinated me – although I have found that clinically defining some of the finer sub-divisions allergic and non-allergic urticarias can be a little taxing (see causes mnemonic FIT MID CHIMP)
To add more confusion to the mix, I thought I might introduce some images from recent cases of physical urticaria…hoping for some erudite comments from the allergy experts in the readership.
Palmaris slapus abdominus
Recently I treated a patient with alcohol induced Palmaris slapus abdominus.
This rare condition is prevalent amongst athletes, particularly males in their early 20′s playing rugby at an elite level. Predisposing factors include significant anaerobic exercise (e.g. Super XV match); ethanol imbibing (e.g. post match beers) and the close presence of an immediate personal physical threat (e.g. prop forward).
The condition was treated symptomatically by avoidance of provocative stimuli (removing the subject from the immediate physical threat) and the administration of 10mg loratadine (non-sedating anti-histamine).
This phenomenon appears to be a variant of immediate pressure non-allergic urticaria. However, the precise classification of this urticarial manifestation is uncertain as it falls within the realms of dermatographic, cholinergic and pressure induced urticaria.
Hopefully more team victories will allow for further study and evaluation of this phenomenon.
Physical urticaria
A proportion of patients with chronic urticaria have physical urticaria, i.e. urticaria incited by a physical stimulus such as cold, vibration, or pressure.
- Pressure urticaria – an uncommon form of physical urticaria which may occur immediately (within minutes) after a pressure stimulus; however, more commonly, pressure urticaria develops after a delay of 4-6 hours after a pressure stimulus. Wheals last for 8-72 hours with the hands, feet, trunk, buttocks, legs, and face are the most common areas affected. Lesions can be induced by a variety of stimuli, including standing, walking, wearing of tight clothes, or sitting on a hard surface.
- Dermatographic urticaria – one of the most common types of urticaria, in which the skin becomes raised and inflamed when stroked, scratched, rubbed, and sometimes even slapped. Firm stroking of the skin produces an initial red line (capillary dilatation), followed by an axon-reflex flare with broadening erythema (arteriolar dilatation) and the formation of a linear wheal (transudation of fluid/edema) termed the triple response of Lewis. The exaggerated response to constitutional whealing tendency occurs in 2-5% of the population and is termed dermographism.
Additional testing needs to be done to formally classify Palmaris Slapus Abdominus into the correct sub-classification of physical urticaria. Options for further stimulus testing have been provided by @DrVes of AllergyCases.org and include
- Dermographism: Stroking with narrow object, e.g. a tongue depressor (see below)
- Cold urticaria: ice cube test
- Heat urticaria: test tube water at 44°C (111°F)
- Pressure urticaria: Sandbag test or a bag with heavy books
- Vibratory urticaria: vibration with laboratory vortex for four minutes
- Cholinergic urticaria: exercise for 20 mins or leg immersion in 44°C (111°F) bath
- Aquagenic urticaria: challenge with tap water at various temperatures
It is of interest that testing of the subjects children revealed an increased propensity towards dermographism…
About Mike Cadogan
Hi Mike,
This looks like a case of dermatographic urticaria (the usual disclaimers apply: no evaluation, opinion or recommendation can be provided without collecting history and examining the patient).
There are tests that can distinguish between the different types of urticaria -- listed on AllergyCases.org and referenced in the text above.
Cetirizine is generally more effective in controlling the symptoms of urticaria, and therefore preferred to loratidine. Patients with chronic urticaria may require 2-4 time the typical dose to control their symptoms.
One simple correction: the URL of the website is AllergyCases.org (not .net).
Thank you for sharing this illustrative case, and I hope this comment is helpful and adds meaningful info to the discussion.
Thank you Dr Ves
That was exactly the kind of comment I was looking for…will certainly give Cetirizine a go in this case
Mike
Can the slapper be cited by the slapee based on fingerprints taken from the wheals? Brilliant case!
The Slaper was correctly identified through fingerprint testing…and the fact that he was in close proximity to the Slapee at the time of dermatographic insult
One wonders (as Haney Mallemat has suggested) whether the slapper was caught red handed?
C
The poor chap looks as though he was slapped incredibly hard. What an incredibly interesting condition though.
Glad to see LIFL incorporating forensic investigative measures in treating acute slapus cases.
Thumbs up also to the serious Dr. Ves’s whose reply was perfect here on LIFL. Who says Doctors can’t treat acute Palmaris slapus abdominus while maintaining a poker face?