Chinese Journal of diagnosis and treatment of urticaria 2014 Edition

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This guide is based on the 2007 Edition (1), combined with the research progress in recent years at home and abroad, mainly by the Chinese M

Content

This guide is based on the 2007 Edition (1), combined with the research progress in recent years at home and abroad, mainly by the Chinese Medical Association of Dermatology and Immunology branch members of the immunology group repeatedly discussed and revised for the reference of domestic counterparts. In the revised guidelines of personnel (in alphabetical order): Zhang Jianzhong, Zhao Bian, Bi Zhigang, Lu Hao, Gu Heng, flying forward, Guo Zaipei, Liu Yanqun, Xiao Ting, Xu Jinhua, Yao Zhirong, Ma Lin, Qiu Xiangning, Deng Danqi, Du Juan, Li Hui, Li Wei, Liu Lingling, Pan Meng, Tu Caixia, Lu Dong Qing, Xie Zhiqiang, Li Linfeng, Jin Jiang, Lv Xinxiang, Xia Jiping, Zhang Xiaoming, Wang Peiguang, Lin Youkun, Zhang Litao, Zhao Ming, Yao Xu, Yang Huimin, Lu Bin, Feng Aiping, Yang Ling, Zhu Xiang, Zhang Junling, lotus, agricultural Song Zhiqiang, Zhu wu.

A definition

Urticaria is a localized edema due to the expansion of skin and mucous membrane and the increase of permeability. The clinical manifestations were the size of the wheal with itching, may be associated with angioedema. Chronic urticaria refers to the wheal weekly at least 2 episodes, lasting over 6 weeks in 2. A small number of patients with chronic urticaria can also be manifested as intermittent seizures.

Two, etiology

Acute urticaria can often find the cause, but the cause of chronic urticaria is more difficult to identify. It is usually divided into exogenous and endogenous (2-3). Exogenous factors was temporary, including physical stimulation (friction, pressure, cold, heat, sunlight, etc.) (animal protein food such as fish, shrimp and crab, shellfish, eggs, plants or fruits such as lemon, mango, plum, apricot, strawberry, walnut, cocoa, garlic, tomatoes so, rotten food and food additives), drugs (such as immune mediated penicillin, sulfa drugs and serum preparation, various vaccines, or mast cell non immune mediated release agents such as morphine, codeine, aspirin), implants (artificial joint IUD, stapler, heart valves, Department of orthopedics steel plate, steel nails and Gynecology and movement etc.). Endogenous factors for more continuity, including mast cells on IgE Gao Min sensibility, chronic occult infection (bacteria, fungi, virus and parasite infection, such as Helicobacter pylori infection in a few patients may be important factors), tired or nervous, for IgE or high affinity IgE receptor in autoimmune and chronic diseases such as rheumatic fever, systemic lupus erythematosus, thyroid disease, lymphoma, leukemia and inflammatory bowel disease. In particular, chronic urticaria is rarely mediated by allergen (2-3).

Three, pathogenesis

The pathogenesis of urticaria is still not very clear, which may involve infection, allergic reactions, allergic reactions and autoimmune reactions. Mast cells play a central role in the pathogenesis of the disease, its activation and degranulation, histamine, leukotrienes, prostaglandins, leading to release, is the key to the effect of urticaria pathogenesis, prognosis and treatment response in 3. The mechanisms involved in the activation and degranulation of mast cells are immune, non immune and idiopathic. Immunological mechanisms including autoimmunity, IgE or IgE for high affinity IgE receptor dependent and antigen antibody complexes and complement mediated pathway; non immune mechanisms including mast cells release agent directly induced induction of small molecular compound fake food allergen reaction, or non steroidal anti-inflammatory drugs alter arachidonic acid metabolism there are a few; urticaria is still unable to elucidate its pathogenesis, and may not be dependent on mast cell activation 2-4.

Four, clinical manifestations and classification

The clinical manifestations of urticaria urticaria, the onset of a variety of forms, many accompanied by itching, a minority of patients with angioedema. According to the mode of onset, combined with clinical manifestations, urticaria can be clinically classified [2]. There are some differences in clinical manifestations of different types of urticaria, see table 1.

Five, diagnosis and differential diagnosis

1: detailed history and physical examination should be collected and a comprehensive physical examination, including the possible predisposing factors and mitigating factors, disease duration, seizure frequency, duration of skin lesions, circadian variation, wheal size, number, shape and distribution of wheal, concomitant vascular edema, accompanied by itching or pain subsided after have pigmentation. In the past personal or family history of allergy and infection history, visceral disease history, trauma history, surgical history, medication history, mental status, menstrual history, living habits, living environment and working environment and previous treatment response.

2 laboratory tests: urticaria usually does not require additional testing. Acute patients can check the blood, to understand the disease is related to infection or allergy. In patients with chronic severe illness, such as longer duration or on regular doses of antihistamines in the treatment of poor response, may be considered for the relevant inspection, such as blood, eggs, liver and kidney function, immunoglobulin, erythrocyte sedimentation rate, C-reactive protein, complement C and various autoantibodies. If necessary, allergen screening, food diary, autologous serum skin test (ASST) and identification of Helicobacter pylori infection can be carried out to exclude and determine the role of related factors (5). The role of IgE mediated food allergens in the pathogenesis of urticaria is limited, and the results should be analyzed. Conditional units can be used to carry out a double-blind, placebo-controlled food challenge test.

3 Classification: combined with history and physical examination, urticaria was divided into spontaneous and induced. According to the former course of over 6 weeks were divided into acute and chronic, the latter according to the onset is associated with physical factors, divided into physical and non physical urticaria, and further classified according to table 1 definition. There may be two or more types of urticaria in the same patient, such as chronic idiopathic urticaria and urticaria.

4: the main differential diagnosis and identification of urticarial vasculitis, which usually lasts 24 h above the skin wheal, recovery after leaving pigmentation, suggestive of vasculitis pathological change. In addition to performance and for other disease wheal or angioedema such as urticaria type, serum sickness reaction, papular urticaria, Staphylococcus aureus infection, adult Still disease, hereditary angioedema and identification.

Six, treatment

1 Education: education should be patients with urticaria patients, especially in patients with chronic urticaria, this disease of unknown etiology, recurrent disease, prolonged course, except for a handful of concurrent respiratory or other symptoms, the vast majority is benign after 6-7.

2 cause of disease treatment: to eliminate the cause of the cause of the disease is conducive to urticaria or spontaneous regression (6-7). The treatment is mainly from the following aspects: 1. Detailed history is the most important discovery methods may cause or causes; the induced urticaria, including physical and non physical urticaria patients can improve clinical symptoms, avoid the corresponding stimulus or predisposing factors, and even more; when the suspected drug induced urticaria, especially is a non steroidal anti-inflammatory drug and angiotensin converting enzyme inhibitors, can be considered to avoid (including drug similar chemical structure) or other alternative medicine; clinical suspicion and infection and (or) chronic inflammation associated with chronic urticaria, in other treatment resistant or invalid can consider anti infection or control of inflammation and other treatment, some patients may benefit. Such as the treatment of anti Helicobacter pylori has certain curative effect on associated with Helicobacter pylori associated gastritis and urticaria; of suspected food related urticaria, encourage patients to keep a food diary, looking for food and may be avoided, especially in some natural food components or certain food additives can cause non allergic reaction the presence of urticaria; for the Fc epsilon RIa chain or IgE autoantibodies in patients with ASST positive or confirmed, conventional treatment is invalid and severe illness can consider adding immunosuppressive drugs, injections of autologous serum or plasma replacement therapy.

3 control of symptoms: drug selection should follow the principles of safe, effective and regular use, in order to improve the quality of life for patients. It is recommended to develop and adjust the treatment plan according to the patient's condition and response to treatment. See figure 1.

(1): second generation preferred first-line treatment of non sedative or low sedative antihistamines, effective treatment after gradually reduce the dosage to achieve the effective control of the wheal as standard. In order to improve the quality of life of patients with chronic urticaria, the course of treatment is generally not less than 1 months, if necessary, can be extended to 3 ~6 months, or longer. The first generation antihistamine therapy is effective in the treatment of urticaria, but its clinical application is limited due to its central sedative and anticholinergic effects. In the attention of contraindications, adverse reactions and drug interactions, etc., can be chosen as appropriate. The generation of antihistamines including chlorpheniramine, diphenhydramine, doxepin, promethazine, ketotifen, two generation antihistamine drugs include cetirizine and levocetirizine, loratadine, desloratadine, fexofenadine, according to A Vastin, Baskin, and mizolastine, epinastine olopatadine etc..

(2): 1 ~ second-line treatment after 2 weeks can effectively control symptoms using conventional dose, taking into account differences, different individuals or types of urticaria in response to treatment choice: the replacement of varieties or informed consent is obtained under the condition of increased 2 to 4 times the dose; combined with first generation antihistamines can be taken before going to bed, in order to reduce adverse reactions; combined with second generation antihistamines such as loratadine, advocate the combined use of drugs and desloratadine combined with similar structure, to improve the anti-inflammatory effect; combined anti leukotriene drugs, especially for non steroidal anti-inflammatory drugs induced urticaria.

(3) the treatment of the three line: for the treatment of patients who are not effective, you can consider the following treatment (6-9): cyclosporine, daily from 3 to 5 mg/kg, oral administration of 2 ~. Because of the high incidence of adverse reactions, it is only used in patients who are serious and do not respond to any dose of antihistamines. Glucocorticoid, applicable to acute, severe laryngeal edema or accompanied by urticaria, prednisone 30 ~ 40 mg (or equivalent dose), oral administration of 4 ~ 5 d after discontinuation of the drug is not recommended for routine use in chronic urticaria. Immunoglobulin, such as intravenous immunoglobulin, 2 g daily, with a total of 5 d, suitable for severe autoimmune urticaria. Biological agents, such as foreign studies show that omalizumab (omalizumab, anti IgE monoclonal antibody) in the treatment of refractory chronic urticaria and the curative effect of 10. At the same time for phototherapy, chronic spontaneous urticaria and artificial urticaria in the treatment of antihistamines can try UVA and UVB for 1 ~ 3 months.

(4) in the treatment of acute urticaria: positive and etiological factors and oral antihistamines drugs can not effectively control symptoms, can choose glucocorticoid prednisone: 30 ~ 40 mg, oral administration of 4 ~ 5 d after discontinuation, or equivalent dose of dexamethasone intravenous or intramuscular injection, especially for severe or with laryngeal edema urticaria; 1: 1000 0.2 ~ 0.4 ml epinephrine solution subcutaneous or intramuscular injection, can be used for acute urticaria accompanied with shock or severe urticaria and angioedema.

(5) the treatment of induced urticaria: induced urticaria is relatively poor in the treatment of conventional antihistamines, the treatment is not effective, to select some special treatment [1, 6-9], see table 2.

(6) treatment of pregnant and lactating women and children: in principle, avoid the use of antihistamines (11) during pregnancy. But as recurrent symptoms, seriously affect the life and work of the patients, must use antihistamine treatment, patients should be informed of the drug is absolutely safe and reliable, such as selection of loratadine and other drugs is relatively safe and reliable in the case of the pros and cons. Most antihistamines can be secreted into milk. In comparison, cetirizine and loratadine in milk secretion is low, lactating women may recommend these drugs, and as far as possible the use of low dose. Chlorobenzene can be sensitive to milk secretion, reduce appetite and cause drowsiness in infants, should avoid the use of.

Non sedative antihistamines are also the first-line treatment for urticaria in children (11-12). There is a significant difference between the minimum age limit and the use of different drugs. Similarly, in the treatment of ineffective children, can be combined with the first generation (in the evening) and the second generation (daytime use) antihistamines, but should pay attention to the impact of sedative antihistamines to children's learning and so on.

(7) Chinese medicine: Chinese medicine therapy has certain curative effect in the treatment of urticaria, need dialectical therapy.

Author Hao Fei, Song Zhiqiang, Lu forward

Reference

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