Urticaria after sexual activity

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

A 25-year-old Caucasian male is at the allergy clinic for evaluation of chronic urticaria for the last one and a half years, precipitated by sexual activity, hot showers, exercise, pressure and touch. The urticarial lesions appear on his trunk, arms, and face. He reports no angioedema, shortness of breath (SOB), wheezing, abdominal pain or any other systemic symptoms. There is no history of loss of consciousness or reaction to cold weather.

His primary physician mentioned that the patient has had wheals/rash on his abdomen after having sex with his wife. The rash occurs almost every time after sex and lasts several minutes. It begins on his back and wraps around to his abdomen but has occasionally been present on his neck. It shows up during of slightly after sex and resolves within one hour afterward. He states that his wife has attempted to stop use of various lotions, body creams etc. and rarely wears perfume. His physician suspected that the rash might be due to contact dermatitis to some cosmetic product used by the patient's wife. CBCD, ESR and ANA were all within normal limits. He was referred for skin testing.

The patient shows a picture of the rash from his cell phone:


Urticarial lesions on the trunk. Image source: Wikipedia, public domain.

Past Medical History (PMH)

Negative, apart from urticaria for one and a half years.

Medications

None.

Physical examination

Normal.

What is the most likely diagnosis?

Chronic urticaria? What type?
Dermatographism?
Contact dermatitis?

What diagnostic test would you suggest?

Pressure test for dermatographic urticaria with a tongue depressor.

What happened?

The test for dermatographism was strongly positive on both forearms:


Dermatographic urticaria is sometimes called "skin writing". Image source: Wikipedia, public domain.

What treatment would you suggest?

The patient has chronic urticaria and dermatographism. The most likely explanation of his symptoms is dermatographism, although physical urticaria, and specifically cholinergic urticaria cannot be completely ruled out. Vibratory urticaria is typically observed at the friction site rather than in widespread distribution and is therefore unlikely in his case.

Contact dermatitis or a reaction to any cosmetic products is unlikely with his clinical history. Skin prick testing or patch testing is not indicated.

The patient was prescribed a H1- and H2- blocker, loratidine 10 mg po daily and ranitidine 150 mg po daily. He is to follow up with the allergy clinic in 3 months.

Summary

There is a mnemonic for fifferential diagnosis of chronic urticaria: VIP

Vasculitis, confirmed by biopsy
Idiopathic, 75% of patients
Physical, benign

Physical urticaria

Physical urticaria is defined as hives provoked by physical stimulus such as:

CDC S (mnemonic)

Cold urticaria due to cooling the skin
Dermographism due to stroking the skin
Cholinergic urticaria due to exercise, emotion, or heat
Solar urticaria due to sun exposure

Physical urticaria can be confirmed by challenge testing, and is best treated symptomatically by avoidance of provocative stimuli and antihistamines.

Testing procedures for diagnosis of physical urticarias depend on the cause (stimulus):

- Dermographism: Stroking with narrow object, e.g. a tongue depressor
- Cold urticaria: ice cube test
- Heat urticaria: test tube water at 44°C (111°F)
- Pressure urticaria: Sandbag test or a bag with heavy books (Middleton's Allergy textbook, 2 volumes)
- Vibratory urticaria: vibration with laboratory vortex for four minutes
- Cholinergic urticaria: exercise for 15-20 minutes or leg immersion in 44°C (111°F) bath
- Aquagenic urticaria: challenge with tap water at various temperatures

References

Urticaria: A Short Review. V. Dimov. Clinical Notes in Allergy and Immunology.
Chronic Idiopathic Urticaria. Current Opinion in Allergy and Clinical Immunology, Medscape, 2003.

Related reading

Flickr user: "I have a weird allergy called "Dermatography" where the skin welts up from contact"
"Young mother must wrap up all year round because she is allergic to the cold"http://goo.gl/w25WB - Cold urticaria in Daily Mail.
Self-referential illustration of dermatographic urticaria. Wikipedia, Creative Commons Attribution-Share Alike 3.0 Unported license.

Published: 03/10/2010
Updated: 03/10/2012

1 comment:

Ben said...

Yeah, I would definitely suspect cholinergic urticaria to be involved. It also sounds like dermatographia, or even delayed pressure urticaria.

I have had cholinergic urticaria for nearly 8 years now, and it is a big frustration to deal with. The fact that the patient developed these hives with heat and physical activities suggested to me that he has Cholinergic urticaria.

It seems that some individuals do have multiple urticarias sometimes. Some people on my own forum even have both cold urticaria and cholinergic urticaria. So I would definitely suspect 2-3 urticarias.