We report the case of a patient with three forms of physical urticaria and his response to treatment.
Methods:
An atopic asthmatic 11 year old male was evaluated for a history of recurrent pruritus with a variable, erythematous rash unresponsive to therapy. Since the age of five years, he has experienced small red, raised, pinpoint, pruritic “bumps” over his entire body except the palms of his hands and soles of his feet. The duration of the lesions was generally 5 minutes to about one hour. They occurred with exercise, stress, cold air, and cold water. At the time of the evaluation, the patient was treated with oral levocetirizine 5mg daily and hydroxyzine 50mg at bedtime without resolution of symptoms.
Results:
In clinic, the patient had a positive ice cube test, a positive dermatographia test and a negative warm test tube test. Methacholine and autologous sweat testing were declined. Otherwise he had a normal physical examination with a negative Darier sign. Laboratory studies did not reveal a disease process responsible for the urticaria. Based upon his historical symptoms and clinical findings, he was diagnosed with three distinct types of physical urticaria; cholinergic urticaria, cold urticaria and dermatographia.
The dose of anti-histamine therapy was doubled and the patient returned to clinic in four weeks to report that his symptoms were slightly improved but had not resolved.
Conclusions:
Physical urticarias are usually controlled by antihistamine therapy but refractory cases are not uncommon. This patient also has poorly controlled asthma for which he is scheduled to start omalizumab therapy upon turning twelve in one month. We will continue to follow this case to observe if omalizumab has an effect upon his urticarial symptoms.