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Year : 1990  |  Volume : 56  |  Issue : 2  |  Page : 109-111

Evaluation of the causes of physical urticarias

Correspondence Address:
Mohan Singh

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Five hundred patients with urticaria were evaluated for physical factors. While 415 (83%) patients associated one or more physical factors in their history, only 37% were found to be suffering- from physical urticaria following tests. These included symptomatic dermographism (16.38%), cholinergic urticaria (10.84%), cold urticaria (8.43%). solar urticaria (0.72%), pressure urticaria (0-48%) and delayed cold urticaria (0.48%). The study stresses the, importance of doing physical challenge tests in all patients since historical iuivicions were not always confirmed on subsequ6nt tests. Moreover, some patients of cold chofinergic urticaria were not aware of the precipitating factors and did not provide any clue in the history.

Keywords: Physical urticaria

How to cite this article:
Singh M, Kaur S, Kanwar A J. Evaluation of the causes of physical urticarias. Indian J Dermatol Venereol Leprol 1990;56:109-11

How to cite this URL:
Singh M, Kaur S, Kanwar A J. Evaluation of the causes of physical urticarias. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2020 Jul 13];56:109-11. Available from:

Physical urticarias are a unique subgroup of chronic urticarias in which wheals can be repeatedly induced by the corresponding physical stimuli. Ever since the publications of Duke in 1924[1] several researchers have estimated the hospital incidence of physical urticarias.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] However, because of their milder nature, the actual figures may be in excess of the estimated incidence. This study was designed to assess the incidence of physical urticarias in a large city-based hospital.

  Materials and Methods Top

The study group consisted of 500 patients of urticaria attending the allergy clinic of the department. The detailed history and physical findings were recorded in a proforma and regularly updated during subsequent visits. Urticaria was considered acute or chronic depending upon the persistence of symptoms beyond two months and recurrent if the recur­ring episodes were shorter than the symptom­ free periods between episodes. Apart from the usual questions about the existence of infections, intake of drugs, inhalants, foods and food additives, sp.cific attention was paid to associa­tion with the physical factors.

(a) Questioning for cold urticaria included exacerbations during winter months, on exposure to cold water bath or washing, cold wind from fans, outdoor activities, ingestion of cold drinks and other factors leading to a fall in the ambient body temperature.

For the cold challenge test, an ice-cube wrapped in two layers of cotton gauze was held on the volar surface of forearm for five minutes. The test sites ware observed for whealing and subsequently by the patient for any delayed effect.

(b) Cholinergic urticaria was considered if the patient complained of exacerbation of the symptoms during sweating due to heat of sun, walking, cycling, heated rooms, hot water bath, emotional stress and ingestion of hot and spicy food.

Cholinergic urticaria was confirmed by asking the patient to do exercise enough to produce profuse sweating for 20-30 minutes.

(c) Symptomatic dermographism was consi­dered if the patient complained of linear whealing at the scratched sites.

Dermographism was elicited by stroking the back of the individual with a blunt object.

(d)Questions for pressure urticaria included whealing at the sites subjected to prolonged pressure such as belts, brassiere straps, watch strap, standing on floor or ladder for several hours and lying in the bed against a hard head rest.

To test the effect of pressure, a thick multi-layered cotton belt with 2 suspended weights of 15 kg was placed on the thigh for 30 minutes.

(e) Solar urticaria was considered if the ratient complained of erythema and wheals on exposure to sunlight and not other sources of heat.

Confiunation was done by asking the patient to stand in the sunlight for 5 minutes.

(f) A history of urticaria developing on coming in contact with water during bathing or otherwise was considered suggestive of aquagenic urticaria.

Tests for aquagenic urticaria included immersion of hands in water at room temperature for 15 minutes.

(g) Development of urticai is on coming in close contact with hot objects suggested heat urticaria.

Warm stimulus test was performed by applying a test tube filled with warm water at 45°C for 5 minutes.

In addition to the routine hemogram, blood bioch,,mistry, 3 stool examinations by the for­mol-ether concentration method, urine, radiolo­gical and, bacteriological examinations, special investigations like collagen profile, cryoproteins, cryofibrinogen, HbsAg and VDRL were also performed in relevant cases. Food additive challenges, diet diaries and diet elimination tests were also done wherever necessary.

  Results Top

Of the 500 patients, 415 incriminated physical factors for the precipitation of urticaria. Eighty five patients who had no history of physical stimuli inducing urticaria were excluded for analysis and investigated for other causes.

The sex distribution was nearly equal and the ages ranged from 1 to 69 years. The mean age of onset of urticaria was 31.2 + 13.5 years. [Table - 1] shows the incidence of various types of physical urticarias as mentioned in the history and corroborated by the investigations. The largest group was symptomatic dermographism patients who complained of whealing following scratching. Of these 68 patients, forty patients experienced other than only linear pattern of wheals also. Hence these patients did not have true symptomatic dermographism. The other common groups were cholinergic urticaria, cold urticaria and pressure urticaria. Very few patients, 15 only, suggested solar and aquagenic factors responsible for urticaria. The suspicion of a cause from the history however, was not always substantiated by the provocation tests and follow-up. The etiology could be established by the physical tests in only 37% patients. Most patients with physical urticarias were younger (24.5±8.8 years). The sex ratio was equal in symptomatic dermographism and cold urticaria patients but patients with cholinergic urticaria showed a marked male preponderance.

  Comments Top

In spite of the growing interest in physical urticarias during the last couple of decades, there are few publications on the incidence of physical urticarias which is reported to vary from 2.3% to 32%.[2],[3],[4],[5],[6],[7],[8],[9],[10] The incidence may be affected by geographical, ethnic, age and sex factors of the populations studied. Also, factors like patient selection method, techniques of physical tests and diligence in search for a cause may also be responsible.

The incidence of cold urticaria has been reported to range from 9.5% to 20%.[9],[10],[11] Thernio-stimulator has been used to test cold urticarias and is claimed to be superior to the simple ice cube tests.[12],[13] Cholinergic urticaria has been variably reported in 1.3% to 18% patients.[3],[4],[5],[8],[9] The reported incidence of symptomatic dermographism varies from 0.8% to 13%.[3],[4],[5],[6],[9] Only three groups of workers have reported the incidence of pressure urticaria as 0.8%, 0.4% and 0.6%.[2],[5],[7] Solar urticaria has been seen in 0.8% and 0.5% patients.[2],[3],[4],[5]

The incidence of cold and cholinergic urtica­rias in our patients is comparatively less than that reported by Pasricha and Kanwar[9] in the same ethnic population in spite of the fact that we subjected all our patients to the laboratory physical tests. Nevertheless, we consider it important to do the complete battery of physical tests in all patients as three patients of cold urticaria and 12 patients of cholinergic urticaria were not aware of the precipitating physical factors and did not provide any clue in the history. The largest group in our patients had symptomatic dermographism(11.5%). In addi­tion, rarer types of solar, pressure and delayed cold urticarias were also seen.

  References Top

1.Duke WW : Urticaria ca ised specifically by the action of physical agents (light, cold, heat, freezing, burns, mechanical irritation and physical and mental exertion'), JAMA, 1924; 83 :3-6.  Back to cited text no. 1    
2.Green GR, Koelsche GA and Kierland RR Etiology and pathogenesis of chronic uticaria, Ann Allergy, 1965: 2 3 : 30-36.  Back to cited text no. 2    
3.Moore-Robinson M and Warin RP : Some clinical aspects of cholinergic urticaria. Brit J Dermatol, 1968; 80 : 794-799.  Back to cited text no. 3    
4.Miller DA, Freeman GE and Akers WA : Chronic urticaria. A clinical study of fifty patients, Amer J Med, 1968: 44 : 68-86.  Back to cited text no. 4    
5.Champion RH, Roh.erts SOB, Carpenter RG et al Urticaria and angio-oedema. A review of 554 patients, Brit I Dermatol, 1969; 81 : 588-597.  Back to cited text no. 5    
6.Sarojini PA, Gopinathan T and Mohandas PP Studies in 100 cases of urticaria with particular reference to the etiology, Ind J Dermatol Venereol Leprol, 1972; 38 : 132-136.  Back to cited text no. 6    
7.Misra RS, Singh R and Pandhi RK : Essential cold urticaria, Ind J Dermatol Venereol Leprol, 1977; 43 : 242-247.  Back to cited text no. 7    
8.Misra RS, Singh R and Pandhi RK : Urticaria chronica, Ind J Dermatol Venereol Leprol, 1977; 43 : 138-142.  Back to cited text no. 8    
9.Pasricha JS and Kanwar A.J Survey of the causes of urticaria, Ind J Dermatol Venereol Leprol, 1979; 45 : 6-l2.  Back to cited text no. 9    
10.Sehgal VN and Rege V L : An interrogative study of 158 urticaria patients, Ann Allergy, 1973; 31 279-283.  Back to cited text no. 10    
11.Pasricha JS and Nayyar KC : Idiopathic acquired cold urticaria in north India, Ann Allergy, 1975; 34 : 363-365.  Back to cited text no. 11    
12.Pasricha JS and Nayyar KC : Evaluation of cryo­stimulation test for the diagnosis of cold urticaria, Ann Allergy, 1975: 35 : 382-384.  Back to cited text no. 12    
13.Pasricha JS and Nayyar KC : An exaggerated erythema response to a cold-pressure test in patients with cold urticaria, Brit J Dermatol, 1973; 89 587-589.  Back to cited text no. 13    


[Table - 1]

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Ghiya, B., Mehta, R., Bumb, R.
Indian Journal of Dermatology, Venereology and Leprology. 2008; 74(4): 384-385
2 Chronic urticaria: An overview
Yadav, S., Upadhyay, A., Bajaj, A.K.
Indian Journal of Dermatology. 2006; 51(3): 171-177


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