|Year : 2008 | Volume
| Issue : 2 | Page : 177-179
Dipti Bhute1, Bhavana Doshi1, Sushil Pande2, Sunanda Mahajan1, Vidya Kharkar1
1 Department of Dermatology, Seth G. S. Medical College and KEM Hospital, Mumbai, India
2 Department of Dermatology, NKP Salve Institute of Medical Sciences and Research Center, Nagpur, Maharashtra, India
Department of Dermatology, Seth G. S. Medical college and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhute D, Doshi B, Pande S, Mahajan S, Kharkar V. Dermatographism. Indian J Dermatol Venereol Leprol 2008;74:177-9
| Introduction|| |
Dermatographism also called as skin writing, dermographism or dermatographic urticaria is an enigma for dermatologists and immunologists alike. Although simpler to elicit, its clinical relevance or significance is yet to be fully known. When normal skin is stroked with a dull object, it becomes raised and inflamed to assume the shape of the stroke.  The response consists of local erythema followed by edema and a surrounding flare reaction. Exaggeration of this response is known as dermatographism. Dermatographism can appear in persons of any age but is more common in young adults. Peak incidence is in the second and third decades of life.
Symptoms of itching, rash and whealing are induced by scratching, stroking, tight or abrasive clothing or other personal wear. Rubbing, minor pressure or any form of physical stress to the skin may initiate lesions. Scalp, genitalia, mucocutaneous junctions and mucosae are involved less frequently.
| How to Elicit Dermatographism|| |
The diagnosis is usually made by observing the clinical response after using moderate pressure to stroke or gently scratch the skin [Figure - 1]. The site of elicitation of dermatographism is important as areas protected from regular pressure and environmental influences are more reactive than others. For this reason, dermatographism is elicited more markedly over the trunk as compared to the limbs.
As the pressure of a stroke has inter-individual and intra-individual variations, a calibrated instrument known as a dermographometer can be used for applying uniform pressure over the skin. It has a spring-loaded stylus that applies graded and reproducible pressure (of 3600 g/cm 2 ) over the skin and then records skin responses. Although, it can also be used in children effectively, its current use is limited to research settings.
| Pathophysiology of Dermatographism|| |
Firm stroking of the skin produces an initial red line (capillary dilatation) followed by an axon-reflex flare with broadening erythema (arteriolar dilatation) and the formation of a linear wheal (transudation of fluid/edema). This is termed as the triple response of Lewis. An exaggerated form of this response is known as dermatographism. Unfortunately, the so-called exaggeration is highly subjective and thus not enough to distinguish between dermatographism and the triple response of Lewis with precision and surety. The time needed for the response to occur after stroking may help to some extent. Dermatographism usually develops within five minutes of stroking the skin and persists for 15-30 min in contrast to the normal triple response of Lewis that subsides in less than 5-10 min. A short refractory period after clearance of the wheal has been reported in dermatographism.  The exact mechanism of dermatographism remains uncertain but according to many, it is likely to be caused by 'mechanico-immunological' stimulation of mast cells that release histamine. Mechanical trauma is thought to release an antigen that interacts with IgE-sensitized mast cells, which further release inflammatory mediators like histamine into the tissues. This causes small blood vessels to leak, allowing fluid to accumulate in the skin. Other mediators possibly involved are leukotrienes, heparin, bradykinin, kallikrein and peptides such as substance P. Thus, the proposed mechanism simulates a type I hypersensitivity reaction with the difference of being triggered by mechanical trauma and not by external immunologic stimuli. This hypothesis is supported by successful passive transfer of dermatographism to normal subjects by serum or IgE and its association with urticaria syndromes. 
Histopathology of dermatographism shows dermal edema with a few perivascular mononuclear cells similar to acute urticaria. Mixed interstitial infiltrate comprising neutrophils, eosinophils and lymphocytes as seen in late lesions are not seen in dermatographism.
| Types of Dermatographism|| |
The phenomenon of dermatographism has the following morphological features, the unifying character of which is the appearance of urticarial lesions following stroking of the skin.
- Immediate symptomatic dermatographism (factitious urticaria): This perhaps is the most prevalent form of dermatographism seen in dermatologic practice. Along with the exaggerated triple response, the patients experience severe itching. The condition is more common in young adults. Though usually idiopathic, it may follow a drug reaction  (penicillin reaction) or infestations including scabies. A few human leukocyte antigen (HLA) associations have been described with symptomatic dermatographism. They are HLA A2, B16, A1 and B5. 
- Delayed dermatographism: Develops 3-6 h after stimulation, either with or without a preceding immediate reaction and lasts for 24-48 h. The eruption is composed of red nodules. This condition may be associated with pressure urticaria. 
- Red dermatographism: This is a rare form where repeated rubbing is necessary to induce small punctate wheals.  This form is probably seen in seborrheic dermatitis. 
- Follicular dermographism: Transitory, discrete, follicular, urticarial papules occur on a bright erythematous background. 
- Cholinergic dermatographism: Seen in some patients of cholinergic urticaria, whose dermographic response consists of grouped urticarial papules characteristic of cholinergic wheals. Purpura has been noted in severe cases. It can be associated with cholinergic urticaria. ,
- Cold-precipitated dermographism: Dermographism that can be elicited on already chilled skin. 
| Differential Diagnosis|| |
Symptomatic dermatographism has to be differentiated from Darier's sign seen in urticaria pigmentosa and systemic mastocytosis in which the actual number of skin mast cells is increased due to mast cell hyperplasia. However, symptomatic dermatographism is also observed in mastocytosis after stroking uninvolved skin. Whether this phenomenon is a positive, nonlesional Darier sign or dermatographism is not clear as yet.  Symptomatic dermatographism appears at the site of strokes or pressure while urticarial wheals appear de novo . Both are pruritic once apparent. Urticarial wheals are usually well-demarcated, round or annular plaques while dermatographism in a given patient assumes the shapes of the strokes/pressure. Dermatographism disappears within 30 min (except in delayed pressure urticaria) whereas urticarial wheals last longer and disappear within 24 h.
| Significance|| |
Dermatographism is seen in 4-5% of the normal population.  Its prevalence in chronic idiopathic urticaria is reported to be 22%  but a few authors believe that dermatographism is not increased in chronic idiopathic urticaria.  In clinical practice, it is essential to differentiate episodes of dermatographism from chronic urticaria and the search for exogenous or endogenous antigens by intradermal tests or autologous serum skin test respectively, is probably unwarranted.
Dermatographism is also called as mechanical urticaria. In that sense, it is a type of physical urticaria. However, it has been reported in association with chronic idiopathic urticaria (22%), cholinergic urticaria, hypereosinophilic syndrome,  drug-induced urticaria,  reactive polyarthritis with Helicobacter pylori  and endocrinopathies like hyperthyroidism, hypothyroidism, diabetes mellitus,  etc. A single case of familial dermographism probably inherited as an autosomal dominant trait has been reported. 
Cutaneous manifestations of dermatographism may be occasionally associated with mucosal symptoms. Cases of bronchial hyperreactivity  and mucosal affection  have been reported. Oral discomfort resulted in difficultly in maintaining oral hygiene in the patient. 
| False Dermatographism|| |
Apart from classical dermatographism and its types, several other types of cutaneous responses associated with or without stroking of the skin entities have been described as dermatographism. These are as follows:
- White dermatographism: when the skin is stroked with a blunt object, instead of erythema, a white line surrounded by an area of blanching appears due to capillary vasoconstriction. This phenomenon can occur normally but is more pronounced in atopic subjects. 
- Black or green dermatographism: It is seen as staining under rings, metal wristbands, bracelets and clasps caused by the abrasive effects of cosmetics or other powders containing zinc (hard powder) or titanium oxide on gold jewelry. 
- Yellow dermatographism: It has no relation with the process of dermatographism. Yellowish discoloration of the skin results from deposits of bile pigment in the skin in a patient of obstructive jaundice.
| Treatment|| |
Avoidance of precipitating physical stimuli, reduction of stress and anxiety are important factors. H1-antihistamines are the drugs of choice. However, combining H1 and H2 antihistamines has sometimes resulted in better control of the wheals. Other treatment options like NB-UVB therapy and psovalent + UVA (PUVA) therapy have been used with limited success.
| References|| |
|1.||Kontou-Fili K, Borici-Mazi R, Kapp A, Matjevic LJ, Mitchel FB. Physical urticaria: Classification and diagnostic guidelines: EACCI position paper. Allergy 1997;52:504-13. |
|2.||Urticaria, Dermographism, Article Last Updated: Feb 27, 2007, Section 11. |
|3.||Soter NA, Kaplan AP. Urticaria and angioedema. In: Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in general medicine. 6 th ed. New York: Mc Graw-Hill; 2003. p. 1129-43. |
|4.||Smith JA, Mansfield LE, Fokakis A, Nelson HS. Dermographia caused by IgE mediated penicillin allergy. Ann Allergy 1983;51:30-3. |
|5.||Salazar Villa RM, Acosta Ortνz R, Mejνa Ortega J, Martνnez Cairo y Cueto S, Castro Ramos F, Villa Michel ER, et al . Symptomatic dermatographism and HLA antigens. Rev Alerg 1992;39:89-95. |
|6.||Grattan CEH, Kobza Black A. Urticaria and angioedema. In : Burns T, Breathnach S, Cox N, Griffiths C. editors. Rook/Wilkinson/Ebling Textbook of dermatology. 7 th ed. Oxford: Blackwell Science; 2004. p. 47.1 - 47.37. |
|7.||Kaplan AP. Unusual cold-induced disorders: Cold-dependent dermatographism and systemic cold urticaria. J Allergy Clin Immunol 1984;73:453-6. |
|8.||Surjushe A, Jindal S, Gote P, Saple DG. Darier's sign. Indian J Dermatol Venereol Leprol 2007;73:363-4. |
|9.||Jedele KB, Michels VV. Familial dermographism. Am J Med Genet 1991;39:201-3. |
|10.||Cooper MA, Akard LP, Thompson JM, Dugan MJ, Jansen J. Hypereosinophilic syndrome: long-term remission following allogeneic stem cell transplant in spite of transient eosinophilia post-transplant. Am J Hematol. 2005;78:33-6. |
|11.||Warner DM, Ramos-Caro FA, Flowers FP. Famotidine (pepcid)-induced symptomatic dermatographism. J Am Acad Dermatol 1994;31:677-8. |
|12.||Morfνn Maciel BM, Castillo Ramos HA. Reactive polyarthritis and painful dermatographism caused by Helicobacter pylori. Rev Alerg Mex 2002;49:99-102. |
|13.||Andrew's disases of the skin Clinical Dermatology, Dermatographism. 10 th ed, p. 153. |
|14.||Henz BM, Jeep S, Ziegert FS, Niemann J, Kunkel G. Dermal and bronchial hyperreactivity in urticarial dermatographism and urticaria factitia. Allergy 1996;51:171-75. |
|15.||Sunil S, Deepak P, Oral manifestations of dermographism. J Oral Maxillofacial Path 2006;10:36-9. |
[Figure - 1]
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