allergic diseases – anaphylaxis and anaphylactoid reactions, urticaria, angioedema, eczema...

Allergic diseases – anaphylaxis and anaphylactoid reactions, urticaria,

angioedema, eczema

Małgorzata Sokołowska-Wojdyło MD, MSc, PhD

Department of Dermatology, Venereology, Allergology, Medical University of Gdansk, Poland

Anaphylaxis - definition

• the maximal variant of the immediate IgE-mediated allergic reaction that affects the entire body• the antigen is either injected or ingested and then spreads via the blood• contact can happened through the mucosal surfaces or the skin also

Etiology

• medications • preservatives • dyes • foods • occupational exposure • insect toxins

• aeroallergens • seminal fluid • echinococcal cysts • cold • warmth • light

Etiology

• contact urticaria • C1 INH deficiency • systemic mastocytosis • many of the above factors together• idiopathic (cause unknown)

Etiology

Anaphylaxis - diagnostic criteria

I. Pruritus, flushing, urticaria, angioedema

II. Pruritus, flushing, urticaria, angioedema; nausea, cramps; rhinorrhea, hoarseness, dyspnea; tachycardia, hypotension, arrythmias

III. Pruritus, flushing, urticaria, angioedema; vomiting, defecation; laryngeal edema, bronchospasm, cyanosis, shock

IV. Pruritus, flushing, urticaria, angioedema; vomiting, defecation; respiratory arrest, cardiac arrest

In addition to the classic signs of acute urticaria and angioedema, an early clue may be tingling of the tongue, palms, soles and tip of the nose.

Caution!!

Anaphylaxis - investigations

- anamnesis (history) and the observation - prick an patch tests- C1 INH blood level test

Anaphylaxis - treatment

• standard medications and equipment necessary to the resuscitation • avoiding the causing factor

An anaphylactoid reaction

- refers to the same clinical reaction pattern, but in the absence of an acute type I reaction

- differentiation between anaphylaxis and an anaphylactoid reaction - general examination, lab tests, observation

- the patient is treated in the same manner

Urticaria - definition

• common reaction pattern in which pink, itchy or “burning” swellings can occurr anywhere on the body•individual wheals lasting not longer than 24 h, but new ones continuing to appear for days, months or even years.

Urticaria that persists for more than 6 weeks is classified as chronic.

Urticaria - epidemiologyUrticaria - epidemiology

• Appearance - 20-30% of individuals have at Appearance - 20-30% of individuals have at least one attack of acute urticaria in their lifetime least one attack of acute urticaria in their lifetime (urticaria is one of the most common skin (urticaria is one of the most common skin disorders). disorders).

• Occasionaly urticaria is combined with Occasionaly urticaria is combined with angioedema.angioedema.

Urticaria - cause

the signs and symptoms of urticaria are caused by

mast cell degranulation, with release of histamine

Urticaria - classification

1. Physical urticaria:

- Cold urticaria- Solar urticaria- Heat urticaria- Cholinergic urticaria- Immediate pressure urticaria - dermographism- Delayed pressure urticaria

2. Hypersensitivity urticaria

3. Autoimmune urticaria

4. Pharmacological urticaria

5. Contact urticaria

Urticaria - classification

Friedman P.S.: Assessment of urticaria and angio-oedema. Clinical an Experimental Allergy, 1998, 29, 109-112

Urticaria spectrum

Clinical features and course

• Most types of urticaria share the sudden appearance of pink itchy wheals, which can come up anywhere on the skin surface.

• The course of an urticarial reaction depends on its triggering factor.

Cold induced urticaria - Ice Cube Test

Cold induced urticaria - Ice Cube Test ResultCaution! - the linear urticaria along the "running

drip", lower right.

Urticaria - Dermagraphism

What can cause the cholinergic urticaria?

• Exercise • Hot baths/showers• Fever • Occlusive dressings• Spicy food • Emotional stress

The reasons of acute urticariaThe reasons of acute urticaria

1.1. Medications Medications • PenicillinsPenicillins• NSAIDsNSAIDs• ASAASA• CephalosporinsCephalosporins• SulfonamidesSulfonamides• IsoniazidIsoniazid• BarbituranesBarbituranes• CarbamazepineCarbamazepine

2. Insect antigens ( bee, wasp or hornet toxins following 2. Insect antigens ( bee, wasp or hornet toxins following sensitization)sensitization)

3. Infections and infestations ( parasites, hepatitis B, 3. Infections and infestations ( parasites, hepatitis B, infectious mononucleosis, bacterial toxins)infectious mononucleosis, bacterial toxins)

The reasons of acute urticariaThe reasons of acute urticaria

5. 5. Food Food - fish, shellfish- fish, shellfish - coca, chocolate- coca, chocolate - tonik water- tonik water - some spices- some spices - cheese especially with mould- cheese especially with mould - fruits: strawberries, walnuts, citrus fruits, kiwi- fruits: strawberries, walnuts, citrus fruits, kiwi - vegetables: peanuts, beans and peas, tomatoes, celery - vegetables: peanuts, beans and peas, tomatoes, celery root, dillroot, dill

5. Animals5. Animals

Complications

- interference with daily activities- sleep disturbances- depression - asthma- asphyxiaction

The investigations

- anamnesis, history (especially: prescribed drugs)- general medical examination- the physical test- laboratory tests - prick tests - RAST

The differential diagnosis

• insect bites or stings• infestations • erythema multiforme• urticarial vasculitis • dermatitis herpetiformis

Urticaria - diagnostics

Zuberbier T.: EAACI/GA/LEN/EDF quideline: definition, classification and diagnosois of urticaria. Allergy, 2006,61,316-320

The treatment

• to eliminate a cause / triggering factors• the antihistaminica (medicaments)• the diet ex. only rice, potatoes and water 7 days• the mast cell stabilizers ( ketotifen, cromylon sodium) mast cell stabilizers ( ketotifen, cromylon sodium) • the distracters and antipruritic ointents and creamsthe distracters and antipruritic ointents and creams• „ „ the the blind therapy” ( antibiotics, anticandidal drugs,

antifungal agents, antimalarial agents)• systemic steroids, cyclosporine (in case of autological

urticaria)

Angioedema definition

acute subcutaneous edema causing circumsribed irregular cutaneous swelling

Etiology

• medications • preservatives • dyes • food • occupational exposure • insect toxins • aeroallergens • seminal fluid

Feature Angioedema Urticaria

Tissuesinvolved

Subcutaneous and submucosal surfaces (beneath the dermis)

Epidermis (outer layer of skin) and dermis (inner layer of skin)

Organs affected

Skin and mucosa, particularly the eyelids and lips

Skin only

Duration Transitory (usually lasts between 24-48 hours)

Transitory (usually lasts < 24 hours)

Physicalsigns

Red or skin coloured swellings occurring below the surface of the skin

Red patches and weals on the surface of skin

Symptoms May or may not be itchy; often accompanied by pain and tenderness.

Usually associated with an itch; pain and tenderness uncommon.

EczemaEczema

• Contact dermatitis/eczemaContact dermatitis/eczema

- Irritant contact - Irritant contact eczemaeczema (nonallergic) (nonallergic)

- Allergic contact - Allergic contact eczemaeczema• Atopic dermatitis/ eczemaAtopic dermatitis/ eczema• Nummular dermatitis / eczemaNummular dermatitis / eczema• Dyshidrotic dermatitis Dyshidrotic dermatitis • Seborrheic dermatitisSeborrheic dermatitis• Eczema crurisEczema cruris• OtherOther

Irritant Contact Dermatitis (nonallergic)Irritant Contact Dermatitis (nonallergic)

• Acute irritant contact dermatitis

• Cumulative irritant contact dermatitis

• Chronic irritant hand dermatitis

• Hyperceratotic palmoplantar dermatitis

• Acute irritant contact dermatitis develops as a prompt Acute irritant contact dermatitis develops as a prompt inflammatory reaction when skin is exposed to an exogenous toxic inflammatory reaction when skin is exposed to an exogenous toxic agent.agent.

• Toxic substances are encountered in many work places, the Toxic substances are encountered in many work places, the home, the garden and in a variety of hobbies.home, the garden and in a variety of hobbies.

Irritant Contact Dermatitis (nonallergic)Irritant Contact Dermatitis (nonallergic)definitiondefinition

Irritant contact dermatitis due to saliva

Contact Dermatitis - Irritant eczematous and bullous reaction on lower anterior shin 24 hours after patient applied garlic (Allium sativum ) to the leg.

Contact Dermatitis - Irritant eczematous and bullous reaction on lower anterior shin 24 hours after patient applied garlic (Allium sativum) to the leg.

Cumulative Irritant Contact DermatitisCumulative Irritant Contact Dermatitis

• Chronic dermatitis that develops following cumulative exposures Chronic dermatitis that develops following cumulative exposures to irritant substances; any single exposure would not be suuficient to irritant substances; any single exposure would not be suuficient to produce clinical problems.to produce clinical problems.

• Most industrrial hand dermatitis falls into this category.Most industrrial hand dermatitis falls into this category.

• Chronic exposure to irritating and drying substances such as Chronic exposure to irritating and drying substances such as cutting oils, chemicals, cement, tars etc.cutting oils, chemicals, cement, tars etc.

Chronic Irritant Hand DermatitisChronic Irritant Hand Dermatitis

• This is the This is the prototype of a chronic irritant contact dermatitis or prototype of a chronic irritant contact dermatitis or cumulative toxic reactioncumulative toxic reaction..

• The cause is only rarely monofactorial; usually a number of The cause is only rarely monofactorial; usually a number of factors combine to cause trouble. factors combine to cause trouble.

• The frequent exposure to water, detergents and other irritating The frequent exposure to water, detergents and other irritating substances is the main problem in case od housewives.substances is the main problem in case od housewives.

• Other groups at risk - hairdressers, nurses and Other groups at risk - hairdressers, nurses and other health-care other health-care workersworkers. .

•Among the men - the main risk groups are those who work in the Among the men - the main risk groups are those who work in the building trades.building trades.

Hyperkeratotic Palmoplantar DermatitisHyperkeratotic Palmoplantar Dermatitis

• The palms and soles are covered with a limited number The palms and soles are covered with a limited number of small, sharply bordered minimally inflamed plaques, of small, sharply bordered minimally inflamed plaques, covered with thickened yellow callus. covered with thickened yellow callus.

• A striking feature is the presence of deep cracks and A striking feature is the presence of deep cracks and rhagades. rhagades.

• The disorder is both very chronic and likely to The disorder is both very chronic and likely to recurrance.recurrance.

Common sources of allergens listed by body regionCommon sources of allergens listed by body region

RegionRegion Common allergen sourceCommon allergen sourceScalpScalp

ForheadForhead

EyelidsEyelids

EarsEars

Oral mucosaOral mucosa

FaceFace

NeckNeck

Trunk, arms, legsTrunk, arms, legs

HandsHands

GenitaliaGenitalia

FeetFeet

Cosmetics, barrettesCosmetics, barrettes

Hat band, protective masks, airborne plant allergens, hair Hat band, protective masks, airborne plant allergens, hair dyesdyes

Cosmetics, nail polish, ophtalmologic productsCosmetics, nail polish, ophtalmologic products

Hearing aids, eyeglass frames, jewerly, ear dropsHearing aids, eyeglass frames, jewerly, ear drops

Dentures, tooth paste, foods, chewing gumDentures, tooth paste, foods, chewing gum

Cosmetics, sunscreens, protective masks, airborne plant Cosmetics, sunscreens, protective masks, airborne plant allergensallergens

Jewerly, cosmetics, clothingJewerly, cosmetics, clothing

Clothing, metal zippers and buttons, cosmeticsClothing, metal zippers and buttons, cosmetics

Occupational exposure, latex gloves, cosmetics, jewerly, Occupational exposure, latex gloves, cosmetics, jewerly, toiletriestoiletries

Toiletries, condoms, spermicidies, feminine hygiene Toiletries, condoms, spermicidies, feminine hygiene productsproducts

Shoe material, antifungals, dyes in socks and stockingsShoe material, antifungals, dyes in socks and stockings

Acute Allergic Contact DermatitisAcute Allergic Contact Dermatitis

• It develops after 24-48 h. It develops after 24-48 h. • The initial findings are limited to the area of contact, The initial findings are limited to the area of contact, but dissemination may occur.but dissemination may occur.• Severe reaction often have swelling and blistering.Severe reaction often have swelling and blistering.

Allergic contact dermatitis / eczema

Mechanism of action – IVth immunological mechanism (Gell Coombs’)

• induction phase

• realising phase

The pathogenesis of allergic contact dermatitis / eczema

The causative factors of allergic contact eczema

nickel, cobalt, chromium rubber ingridients dyes formalin turpentine medicaments cosmetics

The evolution of skin lesions in allergic contact eczema

Exsudative papules

Vesicles acute eczema

Erosions

Exsudative surfaces subacute eczema

Exfolation

Lichenification chronic eczema

Major differences between irritating / toxic Major differences between irritating / toxic and allergic reactionsand allergic reactions

ParameterParameter ToxicToxic AllergicAllergicDose-dependentDose-dependent

Prior exposure Prior exposure requiredrequired

Immunity Immunity involvedinvolved

Percentage Percentage exposed with exposed with reactionreaction

Spread to non-Spread to non-exposed sitesexposed sites

YesYes

NoNo

NoNo

HighHigh

NoNo

PossiblePossible

YesYes

YesYes

LowLow

YesYes

Contact Dermatitis - Allergic Dorsum Right Hand - Neomycin Sensitivity

Allergic Contact Dermatitis Neomycin Sensitivity - Lower Leg

Allergic Contact Dermatitis ; Shoe DermatitisPotassium Dichromate Sensitivity

Dorsal Feet

Allergic Contact Dermatitis; Leather wallet Potassium Dichromate Sensitivity

Left buttock

Allergic Contact Dermatitis - Shoe Dermatitis Potassium Dichromate Sensitivity

Dorsal Feet

Contact Dermatitis - Dorsal Feet

Chronic Allergic Contact DermatitisChronic Allergic Contact Dermatitis

• Can evolve from acute allergic contact dermatitis, creep Can evolve from acute allergic contact dermatitis, creep up subtly with no acute phase or appear on top of up subtly with no acute phase or appear on top of chronic irritant contact dermatitis.chronic irritant contact dermatitis.

• Typical features include symmetric pattern, less sharp Typical features include symmetric pattern, less sharp borders and distant spread.borders and distant spread.

Patch testPatch test

• Is required to confirm the diagnosis.Is required to confirm the diagnosis.

• A known amount of allergen is applied to a small area of skinA known amount of allergen is applied to a small area of skin on a patch, which may be a piece of filter patchon a patch, which may be a piece of filter patch

• An allergic individual will react to the material, but a nonallergic An allergic individual will react to the material, but a nonallergic person will not (irritant reaction can appear).person will not (irritant reaction can appear).

The requirements for testingThe requirements for testing

• Patch testing must be carried out on normal Patch testing must be carried out on normal (healthy) skin. Ideally - at least 3 weeks (healthy) skin. Ideally - at least 3 weeks after clearing of the skin lesions.after clearing of the skin lesions.

• Usually the back or inner surface of the arm Usually the back or inner surface of the arm is used to performed the test on.is used to performed the test on.

• The patches are removed after 48 h. The patches are removed after 48 h.

• The test is read again at 72 (or/and 96 h).The test is read again at 72 (or/and 96 h).

Basic set for patch tests (Poland)

1. Siarczan niklu 10. Chloromycetyna

2. Dwuchromian potasu 11. Balsam peruwiański

3. Chlorek kobaltu 12. Siarczan neomycyny

4. Parafenylenodwuamina 13. Anestezyna

5. Merkaptobenzotiazol 14. Aseptyny

6. Tiuram 15. Formalina

7. Nonox ZA 16. Sublimat

8. Terpentyna 17. Koktajl zapachowy I

9. Kalafonia 18. Koktajl zapachowy II

Th results of the pathc test Th results of the pathc test (how to read)(how to read)

- = no reaction- = no reaction +1 = weak positive reaction with erythema, +1 = weak positive reaction with erythema,

infiltration, possible papulesinfiltration, possible papules +2 = strong positive reaction with erythema, +2 = strong positive reaction with erythema,

infiltration, papules, vesiclesinfiltration, papules, vesicles +3 = extreme positive reaction with marked +3 = extreme positive reaction with marked

erythema, infiltration, confluent papules and erythema, infiltration, confluent papules and vesiclesvesicles

                               ++ reaction

                               +++ reaction

TherapyTherapy

• To avoid the allergic causative factor!!!To avoid the allergic causative factor!!!

Topical TherapyTopical Therapy

• The corticosteroidsThe corticosteroids

• Nonsteroidal antiinflammatory drugs.Nonsteroidal antiinflammatory drugs.

• The antimicrobial agents.The antimicrobial agents.

• Keratolytics ( salicylic acid 5-10%, urea)Keratolytics ( salicylic acid 5-10%, urea)

Systemic therapySystemic therapy

• The corticosteroids.The corticosteroids.

• The antihistaminica.The antihistaminica.

• Antibiotics of necessarry.Antibiotics of necessarry.

• Retinoids.Retinoids.

Thank you for the attention…