Temperature urticaria is an allergic urticaria dermatosis that occurs as a response to the action of a temperature factor. The main clinical symptoms are itching and hyperemia, against which monomorphic blisters appear, existing for no more than 24 hours. Rashes may be accompanied by fever, headache, prodromal phenomena, intoxication. Temperature urticaria is diagnosed on the basis of anamnesis, clinical manifestations and provocative tests. Therapy consists in eliminating the cause of dermatosis, prescribing antihistamines, desensitizing, anti-inflammatory drugs, detoxification.
Temperature urticaria is a transient allergic response of the body to heat or cold. This pathology affects about 7% of the world’s population. For the first time, temperature urticaria was mentioned in the writings of Hippocrates (IV century BC). The clinical symptoms of the disease were described in detail in the XVIII century by the English physician W. Geberden. The discovery of mast cells overflowing with histamine by the German immunologist P. Ehrlich in 1877-79 provided the basis for understanding the pathogenesis of urticaria from the point of view of urticaria formation. In 1961 , representatives of the School of Dermatology Yu . F . Antsypalovsky and A. P. Zinchenko proved the priority in the pathogenesis of cold urticaria of special cold receptors with hypersensitivity to low temperatures, which in combination with the allergic mood of the body explained the fact of the undulating course of pathology and its resistance to therapy.
Temperature urticaria has no gender coloring and age limits. The non-standard nature of this condition is manifested in its ability to accompany the process of warming a person, to occur during summer rain, swimming in tropical latitudes, moving from the sun to the shade, etc. The urgency of the problem at the present stage is associated with a steady increase in the incidence of temperature urticaria, as well as with production and economic losses, since dermatosis mainly affects able-bodied patients.
The starting point of the disease is considered to be thermal or cold exposure. Thermal urticaria is a contact dermatosis, cold urticaria occurs as a reaction of the cold receptors of the skin to a decrease in ambient temperature, the use of ice cream and cold drinks. In addition, this condition can be observed with intravenous administration of drugs whose temperature is below 6 ° C. Sometimes the pathological process is a symptom of other diseases associated with the presence of cold-dependent proteins in the patient’s body (for example, paroxysmal cold hemoglobinuria). Parasitic diseases, colds, foci of focal infection in the patient’s body, diseases of the digestive tract, gynecological pathology are considered factors that increase the likelihood of developing temperature urticaria. There are hereditary autosomal dominant forms of temperature urticaria.
There is no unified concept of the occurrence of pathology. There are immune and non-immune mechanisms of the development of temperature urticaria. When exposed to low temperatures on the skin, mast cells are activated, from which histamine, prostaglandins, leukotrienes (LT D4, C4, E4) are released, vascular permeability increases with the development of edema and the appearance of blisters. In parallel, the body begins to produce special proteins – cryoglobulins, which additionally stimulate the production of histamine and provoke new allergic rashes.
Passive transfer of hypersensitivity to cold mediated by IgG- or IgG-IdM-cryoglobulins is rarely recorded. Contact with cold stimulates the synthesis of IgG autoantibodies to receptors associated with mast cells. Circulating immune complexes are formed, provoking a vascular reaction similar to the histamine response with protein destruction of cells and the formation of blisters. Thermal urticaria is caused by the release of acetylcholine mediators from nerve endings under the influence of heat.
In modern dermatology, there are two main forms of temperature urticaria – cold and heat. Cold urticaria occurs as a skin response to low temperatures. It can be acute (up to 6 weeks) and chronic (more than 6 weeks). Thermal urticaria, which develops in response to the action of high temperatures, is also divided into acute (up to 6 weeks) and chronic (more than 6 weeks).
Cold urticaria includes the following types of pathology:
- Recurrent – seasonal (summer months and late spring are excluded), arising from the action of cold water.
- Reflex – local, manifested by a rash around the place of contact of the epidermis with cold, and general, arising from hypothermia of the entire body. The contact area remains unchanged.
- Familial – genodermatosis with autosomal dominant inheritance.
- Cold erythema, accompanied by painful hyperemia in the area of skin contact and cold.
- Cold dermatitis is a peeling inflammation of the skin in response to hypothermia.
- Cold rhinitis, characterized by symptoms of a runny nose only in the cold.
- Cold conjunctivitis, manifested in the cold.
Thermal urticaria includes two varieties:
- The classic local form that occurs at the point of contact of the skin with heat.
- Non–standard cholinergic form is a variant of the development of the pathological process in response to heat during physical exertion, stress, hot baths, hot weather.
The main feature of the disease is the monomorphic rash and itching. Blisters are localized everywhere, including the skin of the hands, feet, and scalp. The size and appearance of the elements vary significantly – from bubbles with a diameter of several millimeters to drain elements the size of a palm, their outlines resemble a geographical map. The acute form of temperature urticaria is characterized by large blisters that rapidly appear and then regress just as quickly, chronic – a small rash that persists on the skin during the day. Chronic temperature urticaria is an intensely itchy nocturnal dermatosis, which is caused by the daily rhythm of histamine secretion. With acute temperature urticaria, itching is less intense, absent at night.
Temperature urticaria begins spontaneously with itching and hyperemia. Against the background of erythema, bright pink urticaria appear, swelling increases, which squeezes the capillaries of the skin, as a result of which the blisters turn pale. Hemorrhagic sprinkles are possible. Subsequently, the blisters begin to regress from the center, taking the form of rings. With the development of relapse or chronization of temperature urticaria, prodromal phenomena with a sharp rise in temperature, arthralgia and dyspepsia are noted. Temperature urticaria is capable of independent regression, does not leave traces on the skin. Anaphylactic reactions are very rare.
The clinical diagnosis is made by a dermatologist on the basis of anamnesis and monomorphic rash, confirmed by provocative tests. For the cold version, a Duncan test is used: ice is placed on the elbow bend, if after 15 minutes the skin remains inert – there is no urticaria. For a more accurate check, immersion is used by immersing the hand in cold water (below 8 ° C) for 5-10 minutes. The absence of itching and erythema during the test time is a negative result. It is possible to place the patient without clothes for 10-30 minutes in a cold room with a temperature of 4 ° C. In this case, care should be taken to avoid the development of colds or systemic reactions. A physical exercise test is also used at a temperature of 4 ° C for 15 minutes, after which the level of cryoglobulins in the blood is determined.
The local form of thermal urticaria is diagnosed using a sample with a warm object: a glass of hot water (40-48 ° C) is applied to the skin of the forearm for 1-5 minutes or the brush is dipped in water of the same temperature. The inertia of the skin indicates the absence of urticaria. The common form is confirmed when blisters occur in a hot bath with a temperature of 40-48 ° C or by walking for 30 minutes. Thermal urticaria of the cholinergic variant can also be diagnosed by a skin test with metacholine (blisters with intravenous or subcutaneous administration of the substance). To exclude a different genesis of blisters, a blood test for allergens is performed.
They differentiate temperature urticaria with insect bites, dermographism, urticular vasculitis, multiform exudative erythema, strofulus, hereditary angioedema, mastocytosis, secondary syphilis, Leffler, Wissler-Fanconi, Melkersson-Rosenthal syndromes.
It is necessary to eliminate the cause of the disease. In cold urticaria, a combination of antihistamines of the II and III generation, tranquilizers, desensitizing agents, M-cholinoblockers is shown. In severe cases, corticosteroids are prescribed in short courses, detoxification is carried out. In case of anaphylaxis, an urgent intravenous or subcutaneous injection of adrenaline is necessary. You can stop the attack yourself with a special pen-a syringe with adrenaline. Local therapy includes warm oat baths, antipruritic and anti-inflammatory drugs, chatterboxes.
In the thermal version, antihistamines are ineffective due to acetylcholine mediators. Gels and ointments based on atropine, belladonna extract are applied to the lesions 1-2 times a day. In parallel, the exacerbation of concomitant diseases is stopped, the foci of chronic infection are sanitized. The prognosis is relatively favorable, in 50% of cases, temperature urticaria spontaneously resolves during the year. In 20% of patients, the pathology becomes chronic, acquires a persistent recurrent course. Timely and accurate diagnosis and adequate therapy are important, since temperature urticaria in rare cases is complicated by angioedema and anaphylaxis.