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Allergic and itching skin conditions (Urticaria)

Urticaria

 

One of the 20 most common of skin diseases, experienced by 20% of population during their lifetime. Also known as hives or nettle rash. Characterised by transient, oedematous, pruritic, slightly erythematous papules and weals.

 

Urticaria was first mentioned in in the Chinese Medicine literature in the Suwen, known as concealed rash, or concealed wind rash. Angioedema is a term used to describe urticaria of the deeper dermal and subcutaneous tissue rather than the superficial skin. It is characterised by swelling with little or no pruritus, typically of the loose tissue around the eyelids or lips

In a minority of cases, urticaria my cause systemic symptoms depending on site of involvement e.g. hoarseness of voice, respiratory distress, vomiting, diarrhoea, abdominal pain, joint pain, headache, syncope. Seen equally in males and females. Acute urticaria is common in children, chronic urticaria is rare.

 

What it looks like:

The primary lesion is a raised patch known as a weal (oedematous papule) with no scaling. It is firm to touch, with sharp edges. Weals tend to develop very rapidly, and disappear relatively quickly
(from 20 minutes to 8 hours, rarely 1-2 days. If it takes longer to disappear, than it is not urticaria).

 

Colour: varies from red, to pink to white, or some combination (most
typical lesion is white centre with pink/red halo. Angioedema tends to be
flesh coloured.

 

Size: may vary from pinhead size to palm sized to large enough to cover an entire limb. Small superficial lesions are often the itchiest.

Shape: highly variable, tends not to have regular configuration. Weals in
close proximity become confluent forming polycyclic, geographic
patterns; central healing leads to ring shaped lesions. If the palms or soles
are involved, the typical urticarial pattern is not present, the affected area
being tense red and swollen.

 

Occasionally exudation within a weal leads to blistering (seen following
insect bites especially on the legs), rarely haemorrhagic.

 

Side pressure evokes “orange peel” effect which is caused by oedematous
pressure around the follicles.

 

Distribution:

Can occur anywhere.

When the fingers or toes are involved the swelling may well interfere with movement, and lead to joint pains. The face is frequently involved, giving rise to the characteristic swelling of angioedema of eyelids and lips.

 

Aetiology:

Attack by external pathogen: Wind is primary. May combine with cold or
heat to attack the superficial layers of the body disrupting correct function.

Injury by emotions: Hot blood is generated from either stagnant heat in
the heart, or liver.

Injury by food & drink: Damp & heat that in turn generate wind. This is
either from inappropriate food, or due to original weakens of the digestive
system.

Deficiency of qi & blood: Chronic illness, childbirth, constitutional
weakness etc. leads to qi and blood xu. Wei qi is unable to protect the
exterior.

Natural History and Clinical Features:

Can usefully divide into two broad categorise:

Acute urticaria: Acute onset, clears within 4-6 weeks. In most cases
allergen can be found.

Chronic urticaria: Urticaria lesions continue to appear 4-6 weeks after
initial attack.

 

An intense pruritus appears with formation of weals, later becoming less
bothersome. Urticarial lesions are not usually scratched but rather chafed
or rubbed.

An actual lesion tends to last from a few minutes to a few hours; rarely a
day or two. In most cases what the patient believes to be one lesion is
several lesions in close proximity.

Dermographism is no more common in patients with urticaria than in the
general population.

50% of chronic urticarias clear of there own accord within 6 months.

 

Causes:

Very broad classification, although 70% of chronic cases have no clear cut aggravating factors. Acute cases, a causative factor often found.

1. Drugs: the most common known factor in acute cases. Penicillin, Aspirin, salicylates

2. Foods:

The most common foods include shellfish, strawberries, tartrazine and other azo dyes. Also preservatives such as sodium benzoate, and benzoic acid (eg in pickles, sauces, instant coffee, preserved fruit juice and some tinned foods).

3. Infection:

Chronic bacterial or viral infection can be quite an important factor, in acute or chronic urticaria, the most common being Sinus infections, (in one study, 17% of chronic urticaria patients had sinusitis). Infections my be asymptomatic or mildly symptomatic.

4. Internal disease:

Variety of disease can give rise to urticaria. Most important include: autoimmune thyroid disease (in one study 12% of women patients with chronic urticaria had sub clinical thyroid disease), lupus erythramatosis, malignancy.

5. Physical factors:

Contact Stinging nettles, caterpillars, jelly fish, insect bites etc. Cold: Usually seen on exposed areas, face, neck, of arms and legs. Heat very rare unless cholinergic urticaria (small lesions of 2-3 mm that are often triggered following exercise of emotional upset) is included. Pressure: usually due to tight shoes, socks, belts, hats, sitting (buttocks). Most patients with chronic urticaria have some element of pressure urticaria.

Sunlight. Most pronounced in area that are not often exposed, similar to polymorphic light eruption.

6. Other:

Many other rare factors can be involved, e.g. contact with water, x-ray urticaria, vibration urticaria etc.

 

Treatment in mainstream medicine:

Antihistamines are the main stay of treatment.

 

Differentiation and Treatment in Chinese Medicine

1. Wind heat:

Generally seen in acute urticaria, large red weals often with central pallor,

severe itching, worsening of itching with heat, improvement with cold.

Generally effects the upper part of the body.

May be associated with sore throat and slight fever.

Tongue – Red with thin white or yellow coating

Pulse – Floating

 

Some people experience severe itching, pronounced signs of heat, sore throat, constipation, much swelling of the lips and eyelid.

 

2.  Wind cold:

“Cold urticaria”. Lesions tend to be paler in colour, most often seen on exposed areas such as the face, neck, hands & arms, itching is aggravated by cold or exposure to wind, improved by warmth, tends to be better in summer and worse in winter. Tongue – Pale, or normal Pulse – Tight

 

3. Damp of spleen & stomach with wind:

Urticaria is often triggered soon after eating certain foods. Lesions are

associated with nausea and vomiting and abdominal & epigastric pain and

distension.

Diarrhoea or loose stools, poor appetite, fullness and distension of the

abdomen after eating.

Tongue – pale with thin white coating, or thick slippery coating

Pulse – Slippery or soggy

 

Some people experience abdominal distension and bloating, poor appetite, Intolerable itching

 

4. Hot blood generating wind :

Small, red lesions, intensely itchy, dermographism is more pronounced than in other forms, itching is worst in the evenings, by emotional upset, and clearly made worse by heat. Mostly seen in chronic urticaria. Easily feels the heat, sleep disturbance or insomnia, mouth and tongue ulcers. Tongue – Red tip; Pulse – Thready & rapid

 

Some cases experience insomnia, palpitation, restlessness in the evenings with heat and thirst.

 

5. Qi & Blood Xu with Wind :

Chronic urticaria, often most pronounced in the afternoon and evening, or when feels tired. May be accompanied by heaviness of the head, dizziness, lethargy, insomnia, spontaneous or night sweats. Tongue – Pale, possibly swollen with teethmatks. Pulse – Thready, Xu.

 

6. Blood Stasis :

Chronic urticaria, pressure urticaria. Lesions are often dark red or may have a purple hue, mostly seen around the waist, buttocks and ankles. Dry mouth with little desire to drink, purple hue to lips or face. Tongue – Purple Pulse Choppy

 

 

Thanks to Mazin Al-Khafaji