Symptoms
Cholinergic urticaria is a type of urticaria that occurs primarily on the upper body, chest, neck, face, back, and arms. It manifests itself in an initially scattered and then coalescing redness of the skin, itching, burning and a sensation of warmth. At the same time, small wheals form, which are smaller than in other forms of urticaria (pinhead, 1-5 mm). In a severe course, accompanying symptoms such as headache, dizziness, nausea, wheezing and shortness of breath may rarely occur. Skin reactions occur a few minutes after the body temperature is elevated. If the trigger is removed, the symptoms usually disappear within about half an hour, but may last longer. The course is usually mild, severe courses with shortness of breath are rare. The episodes may disappear after a few years. Young adults are frequently affected. In a study of 493 students in Berlin, more than 11 percent were affected (Zuberbier, 1994)! Since the symptoms of urticaria usually pass quickly and are not permanent, those affected do not seek medical treatment and are not sufficiently informed. The condition was first described in 1924 (Duke, 1924).
Trigger
Heat is considered the main trigger. Hives occur when there is a 0.5 to 1.5°C increase in body temperature. Triggers include:
- Emotional stress, anxiety
- Bathing and showering, sauna
- Physical exertion, for example, sports, while hiking, at work.
- High room temperature
- When consuming alcohol or spicy foods, such as cayenne pepper.
- When drinking hot drinks
- Fever
The same person may not react to all triggers.
Causes
The cause of hives is the release of inflammatory mediators such as histamine by degranulation of mast cells. During an episode, an increased concentration of histamine can be detected in the plasma. The actual underlying cause remains unclear. Discussions include autoallergy to the components of sweat and hypohidrosis (decreased sweating). From our point of view, the cold plays an important role, since the complaints occur mainly in the cold season and disappear over the summer. Possibly, a slight frostbite of the skin is the cause. Therefore, it is important to dress sufficiently warm for prevention.
Complications
The occurrence of skin reactions can be physically and psychologically uncomfortable for those affected. It can be a psychosocial problem, leading to feelings of shame and social withdrawal. In contrast, severe complications such as a generalized reaction with bronchoconstriction or hypotension and collapse are rare.
Risk factors
Young people are more commonly affected, and small studies have shown familial clustering.
Diagnosis and differential diagnoses
The diagnosis can often be made on the basis of the patient interview. A provocation test can confirm the diagnosis: symptoms can be elicited by physical exertion and most reliably by a hot bath. When cholinergic substances are injected intradermally (into the skin), symptoms occur in only about one-third of patients. Cholinergic urticaria can be confused with other forms of urticaria, among others:
- Cold urticaria: direct contact with a cold object (e.g., ice cube) or cold environment.
- Heat urticaria: direct contact with a warm object (rare).
- Aquagenic urticaria: direct contact with water causes urticaria (very rare).
- Effort-induced urticaria: occurs during physical exertion 1-2 hours after eating.
Menopausal hot flashes show similar symptomatology, but do not usually occur in younger people and are not accompanied by wheals. Flushing, such as in rosacea, is usually without wheals and itching.
Nonpharmacologic treatment and prevention.
Controlling the main triggers of heat and stress can prevent hives:
- Appropriate clothing
- Do not shower or bathe too hot
- Relaxation techniques
Cold / cooling during the push:
- Briefly in the fresh air to cool down
- Drink a cool drink
- Take off clothes that are too warm
- Evt.Ice pack (eg Nexcare ColdHot, Dermaplast Ice Pack).
Refractory phase:
- After a relapse, there is a symptomless refractory phase of a few hours to a day.
Climate:
- The symptoms occur mainly in winter and often improve in summer.
Drug treatment
In mild cases, drug therapy is usually not necessary, as symptoms disappear quickly during an episode. Antihistamines:
- Antihistamines can be used in self-medication. Hydroxizine is commonly used because it is not only antihistamine, but also has antianxiety and sedative effects. Other 1st and 2nd generation antihistamines such as cetirizine or loratadine are also suitable. High dosages may be necessary. A disadvantage of these drugs are adverse effects such as fatigue.
Skin care products:
- Skin care products such as creams or hydrolotions nourish the skin and can be applied in an acute episode to cool.
Herbal medications:
- Herbal sedatives can be taken preventively for relaxation if stress is a major trigger. Suitable are, for example, valerian, lemon balm, hops, California poppy, kava kava, lavender, orange blossom, passion flower, peppermint or St. John’s wort. Adaptogens such as ginseng, rose root or taiga root are said to increase stress tolerance.
Other medicines:
- Mast cell stabilizers such as ketotifen or cromoglicic acid may be used if prescribed by a physician.
- Glucocorticoids are indicated only in severe courses.
- Psychotropic drugs such as beta-blockers or antidepressants may be used as needed if anxiety or stress is a major trigger or psychological complications occur.
