Urticaria and its homeopathic management- literature review

Dr Anupam Kumar1
Ph.D., M.D. (Hom.),
Professor, ¹Department of Homoeopathic Philosophy &Organon of Medicine,Homoeopathy University, Jaipur.

Dr Diksha  Agrahari²,  Dr Pooja Shukla^2
 2PG  Scholar, Department of Homoeopathic Philosophy &Organon of Medicine,Homoeopathy University, Jaipur.

ABSTRACT :  Urticaria (hives) is a vascular reaction of the skin marked by localized dermal oedema, around 15 to 20% of the general population will have urticaria at least once during their lifetime, which can be triggered  by crude drugs , allergens and also  environmental factors. This review article on Urticaria provides a comprehensive understanding of this  disorder and its homoepathic management.

KEYWORDS: Urticaria, homoeopathy, dermatological disorder

INTRODUCTION:  Urticaria (hives) is a vascular reaction of the skin¹ marked by localized dermal oedema²,the transient appearance of smooth, slightly elevated papules or plaques (wheals)¹,that may be pale or red in the centre and surrounded by a red flare³, that may coalesce to become giant wheals⁴ and that are often attended by severe pruritus.¹

EPIDEMIOLOGY –Approximately 15 to 20% of the general population will have urticaria at least once during their lifetime. Any age group may experience urticaria⁵  but it occurs most frequently after adolescence and highest incidence is found in young adults. ⁴

In young adults of both sexes, acute urticarias are common and chronic urticarias are more common in women, which is commonly seen in their fourth and fifth decades.³ An Indian study showed that out of 500 cases of urticaria, 37% were suffering from physical urticaria.⁶

PRECIPITATING FACTORS 

1. Infections/ infestations:- 

A) Viruses – adenovirus, enterovirus, rotavirus, Epstein–Barr virus, cytomegalovirus ⁷ 

B) Bacteria – Streptococci, mycoplasma pneumonia,⁷ , Staphylococci, Helicobacter pylori, Escherichia coli^8-10 

C) Parasites and Parasitic infestations –Blastocystis hominis, Plasmodium falciparum, ⁷ and strogyloidiasis, giardiasis and amoebiasis etc¹¹

D) Fungal infections -such as onychomycosis, tinea pedis and candida ¹²

2. Drug Hypersensitivity: antibiotics and non-steroidal anti-inflammatory drugs  responsible for childhood acute urticarial ⁷, Aspirin,( alcohol, narcotics (codeine, morphine) and oral contraceptives  may exacerbate chronic urticaria ^13-15
3. Food allergy: occurs after direct skin contact (form of contact urticaria), inhalation or digestion.Symptoms occur immediately in less than 1 h.⁷ food hypersensitivity are mainly due to coloring agents and preservatives, monosodium glutamate and sweeteners.¹⁶ Common urticogenic foods are-milk,chocolate, cheese, eggs, wheat,peanuts, tree nuts, seafood and shellfish,fish tomatoes^17,18
4. Systemic and auto-immune diseases: rheumatic disorders, thyroiditis, neoplasm,hypothyroidism (Hashimoto’s thyroiditis) or hyperthyroidism (Graves’disease), Juvenile idiopathic arthritis, systemic lupus erythematosus,  type I diabetes mellitus and coeliac disease ^19-21
5. Environmental allergens: Dust mites, moulds and animal dander¹⁷ ,Grass pollens, spores, house dust and even tobacco smoke.²²
6. Insects: insect bite or sting mainly by mosquitoes, bees and spiders.¹⁷
7. Physical urticaria: Physical stimuli such as cold, heat, scratch, pressure, vibration. Dermatographism is the most common physical urticaria.¹⁷
8. Idiopathic causes: Most chronic urticaria are idiopathic.²³
9. Psychogenic factors: Depression ²⁴ and anxiety were found frequently in chronic urticaria ¹⁸

10.Blood Groups: common in group A  and this susceptibility decreased in  that order with group AB, O and B.¹⁸

11. Menstrual Cycle And Pregnancy: The most common specific dermatosis of pregnancy is the pruritic urticated papules and plaques of pregnancy which occurs during the 3rd trimester and due to progesterone sensitivity It occurs or worsens only premenstrual phase.¹⁸
12. Genetic Factors : many large families of hereditary angioedema are recorded. Familial cold urticaria is another autosomal dominant disease.¹⁸
13. Miscellaneous: other dermatological conditions such as urticaria pigmentosa, dermatitis herpetiformis, pemphigoid etc may also produce urticaria-like lesions.²⁵

Pathogenesis²⁶

TYPES – In terms of duration- it is of 2 types- ⁵

a) Acute Urticaria – Attack is usually self limited and wheals get resolve within 24 hours. It  may last up to 4-6 weeks.³ sometime associated with angioedema of the lips, face, tongue, throat and, rarely, wheezing, abdominal pain, headaches and even anaphylaxis ² 

b) Chronic Urticaria– Wheals may appear daily or on most days for longer than 6 weeks³. There is spontaneous appearance of wheals so the term chronic spontaneous urticaria (CSU) is introduced ²⁷ 

c) Recurrent Urticaria-There is recurrent attack of urticaria and each episodes of urticaria lasts for more than 6 week.⁵

2- When classified in terms of trigger factors- Trigger factors  are easily identifiable in acute urticaria, as compared to the chronic form.⁵

it is of 2 types- ³ 

(A) Non immunologic or Nonallergic or Ordinary urticaria-These are caused by degranulation of mast cells and histamine is released by mechanisms in which there is not involvement of antigen-antibody reaction ³

Physical urticaria– Wheals occur episodically, in limited areas only in response to an inciting physical stimulus¹⁸.this urticaria comes under Inducible urticaria²⁸  this also belongs to chronic urticaria in which symptoms are not chronic but only visible when physical stimuli are present.²⁷

S.No	Type of Physical Urticaria		Characteristics
1-	Cold contact Urticaria		Elicited by cold objects, air, fluids, or wind 27
2-	Delayed pressure Urticaria		Elicited by vertical pressure. wheals arises after 3-12 h27which are erythematous, non pruritic and are usually painful 18
3-	Heat contact Urticaria		Elicited by localized heat exposure 27 Heat application of immersion of an extremity in water at 38°c for several minutes can cause a sudden appearance of this form of urticaria.There are 2 types of urticaria-18 1-Immediate form – urticaria appears within 15 minutes of heat exposure18 2- Delayed- urticaria appears 30min to several hours after exposure18
4-	Solar Urticaria		Elicited by UV and/or visible light.27 Signs and symptoms may begin either during or within seconds after intense sun light exposure, with ‘burning’ followed by erythema, wheal and flare. The urticaria reaches a peak within 10-15 minutes and persists for 1 or 2 hours.18
5-	Dermographic Urticaria  (Urticaria Factitia)		Elicited by mechanical shearing forces, wheals arising after 1-5 min. 27
6-	Vibratory Urticaria/ Angioedema		Elicited by vibration, for example, jackhammer .27 characterized by itching and swelling within minutes after local exposure to vibration.29,30
Other types of Urticaria
1-	Aquagenic urticaria	Elicited by water 27 ,Pruritc, follicular wheals appear within 2-3 minutes to half an hour of immersion in water.18
2-	Cholinergic urticaria	Elicited by increase in core body temperature, for example, exercise,27 characterized by numerous, superficial, small swellings which sting, smart, or itch and are surrounded by a blush lasting a few minutes only and found in adolescents and young adults like blushing18
3-	Contact urticaria	Elicited by contact with triggering substance27 like exogenous proteins and chemicals 31 characterized by transient localized swelling/whealing response and redness that occurs on the skin28 Oral and perioral urticaria occurs after direct contact of the oral mucosa with food31
4-	Exercise-induced anaphylaxis/ urticaria	Elicited by physical exercise 27 ,occurs in young adults, adolescents within 30 min of exercise. It is typically preceded by cutaneous manifestation with a rapid progression to severe systemic reaction.32

B) Immunologic or Allergic or Idiopathic or Autoimmune Urticaria- There are genes which play a role in urticarial conditions where a strong personal or family history of atopic disorders may be present, ³ there is Specific antigen sensitivity which includes foods, drugs, therapeutic agents, venom, helminthes etc.¹⁸, approximately 50% cases of chronic urticaria remain unexplained and are categorized as Chronic idiopathic urticaria (CIU).²⁵

CLINICAL FEATURES-

Onset-Sudden and unexpected but sometimes there is history of viral infection, immunization, drug therapy (aspirin, penicillin) or any type of food allergy (fish, fruits, nuts) may be present.³³

Symptoms-When wheals are superficial, itching is prominent. Generally, scratch marks are not seen because patients tend to rub rather than scratch.⁵ wheals are worse in the evenings, on nights³³

Sites- Wheals may occur on any part of the body (from scalp to the soles of feet) ^33,4 exp-  In solar urticaria, lesions are found on sun exposed parts.⁵

In delayed pressure urticaria, most common sites are buttocks due to prolonged sitting, hands in workers who work manually, under feet due to prolonged walking and waist due to tight underclothes.⁵

so it may be localized or can be extensive and generalized as to cover almost the entire skin surface¹⁸

Morphology–  Urticarial lesions begins as erythematous macules which develop into pale pink edematous wheals rapidly. Large lesions may be annular/ arcuate with paler centre.⁵

Number and size– Wheals are variable in number and size.Pin point wheal is characteristic feature of cholinergic urticaria whereas small and large wheals are found in cold urticaria.⁵They may occur in size from <1 to many centimeters across or coalesce.³³

Shape– It can be circular, annular, arcuate or serpiginous. Linear wheals are found in dermographic urticaria ⁵

Evolution– Wheals of urticaria last a few hours to 24 hours or  beyond 24 hours⁴ and disappears spontaneously leaving behind normal skin (no pigmentation, no scaling/atrophy)⁵  but new lesions may appear soon as old lesion fades away ⁴

example – wheals of cholinergic urticaria subside within few minutes.⁵

Associated features:

• Fever and malaise
• Headache
• Abdominal pain
• Diaarhoea 
• Vomiting
• Arthralgia
• Dizziness 
• Syncope ⁵

INVESTIGATIONS –Investigations should be guided by the history and possible causes but are often negative, particularly in acute urticaria. Following investigations are required.³⁴

1. Full Blood Count: Eosinophilia in parasitic infection or drug cause. 
2. Total Eosinophil Count: Raised in cases of allergic reaction. 
3. Erythrocyte Sedimentation Rate (ESR) Or Plasma Viscosity: elevated in vasculitis. 
4. Urea and Electrolytes, Thyroid and Liver Function Tests, Iron Studies: reveals an underlying systemic disorder. 
5. Total IGE and Specific IGE to Possible Allergens: e.g. shellfish, peanut, house dust mite. 
6. Antinuclear Factor: positive in systemic lupus erythematosus (SLE) and urticarial vasculitis 
7. Skin Biopsy: if urticarial vasculitis is suspected.
8. Challenge Tests: to confirm physical urticarias 
9. The autologous serum skin test (ASST) 35- for detection of basophil histamine releasing activity with 65-71% of sensitivity and 78-81% specificity 
10. Prick test – performed for suspected foods, food additives along with allergy to dust, mites, fungi and epithelia ³⁵ it is most convenient and least expensive method of allergy testing and result can be made available within 60 minutes. It helps to trace out type 1 (immunoglobulin E) mediated hypersensitivity specifically. ^{36, 37}

The following pattern should be observed before treating the patient- ^{38, 27}

• First onset of CSU (life events?)
• Frequency, duration, severity, shape, size and localization of wheals
• Relevance of symptoms with time of day, day of week (weekend?), season (vacation?), menstrual cycle
• Presence of angioedema, subjective symptoms of lesion (itch, pain) or systemic manifestations (headache, gastrointestinal symptoms, joint pain etc.)
• Family history of urticaria or/and atopy
• Previous or current allergies, intolerances, infections, systemic illnesses
• Psychosomatic and psychiatric diseases
• Surgical implantation and events during surgery
• Gastric or intestinal problems (stool, flatulence)
• Possible precipitating factors (physical stimuli, exercise, stress,food, medications)
• Use of medications (NSAIDs, injections, immunizations,
• hormones, laxatives, suppositories, ear and eye drops, alternative remedies)
• Smoke, alcohol use, personal and social status, occupation, free‑time activities
• Quality of life impairment, emotional impact
• Therapies that have been used, response to treatment 

DIFFERENTIAL DIAGNOSIS

Sl. No.	Disease	Characteristics
1-	Insect bite 39	Often result in itchy bumps (papules) or wheals, felt on exposed sites Central blister (vesicle) Groups of lesions, often distributed asymmetrically More commonly arise in summer and autumn months Individual lesions persist for days to weeks Brownish discolouration that persists for months is often seen in a skin that tans easily. Adults may develop papular urticaria, which is interpreted as a hypersensitivity reaction to insect bites. A biopsy reveals an inflammatory infiltrate that includes eosinophils and spongiosis of the epidermis.
2-	Contact dermatitis39	most of the inflammation in the dermis rather than the more superficial epidermis. It appears at the site of contact with the responsible agent It may arise in irritant contact dermatitis or allergic contact dermatitis Lesions clear up over days to weeks Patch tests may reveal an allergen in allergic cases
3-	Annular erythema 39	begins as a small raised pink-red spot that slowly enlarges and forms a ring shape while the central area flattens and clears. resemble an urticarial weal but often have a trailing scale rings enlarge at a rate of about 2-5 mm/day until they reach a diameter of about 6-8 cm Sometimes the lesions do not form complete rings but grow into irregular shapes.
4-	Urticarial vasculitis40	a small-vessel vasculitis with predominant cutaneous involvement Systemic involvement in urticarial vasculitis affects multiple organs (mainly joints, the lungs, and the kidneys) more frequent and more severe in patients with hypocomplementemia.
5-	Atopic dermatitis41	Maculopapular, scaling, characteristic distribution
6-	Fixed-drug  reactions 41	Offending drug exposure, not pruritic, hyperpigmentation
7-	Henoch-Schönlein purpura41	Lower extremity distribution, purpuric lesions, systemic symptoms
8-	Pityriasis rosea 41	Lesions last weeks, herald patch, “Christmas tree” pattern, often not pruritic
9-	Viral exanthem41	Not pruritic, prodrome, fever, maculopapular lesions, individual lesions last for days
10-	Angioedema17	occur in the deep dermis and subcutaneous tissue Combination of both is known as Urticarial Angioedema Syndrome (UA) that persist for minimum 72 hours. The major difference between two conditions is whether mast cells in superficial dermis that results urticaria or in deeper epidermis that results in angioedema

CONVENTIONAL TREATMENT

• Cooling lotions(e.g. calamine, 0.5% menthol in aqueous cream)³³
• Uses of non sedating antihistamine drugs such as loratadine, cetirizine, levocetrizine etc.²
• Uses of sedating h₁ antihistamine such as chlorpheniramine or diphenhydrmine ¹ at night³³ for those  patient who don’t give response easily for non seadating histamines.
• Oral steroids  in recalcitrant urticaria.²
• Immunosuppressives (methotrexate, azathioprine and cyclosporine) in resistant urticaria ²
• Patient with a history of life threatening anaphylaxis as in peanut or wsap sting allergy, carry adrenaline (epinehrine) injection kit.²

MANAGEMENT

• Remove trigger factors if they are identifiable^33,2
• Avoid aspirin, nsaids, codeine.³³
• Avoid tight fitting or woolen clothing, aquatic activities, cold food, drinks, ice creams depending on the type of physical urticaria suspected ⁴²
• Avoid alcohol overuse, excessive tiredness, stress and overheated surroundings⁴³

HOMOEOPATHIC MANAGEMENT: ⁴⁴
Conventional treatment is efficacious to draw away the superficial lesions which mostly reappear after sometime. According to homoeopathy, no eruption is local and is manifestation of internally deranged vital force, hence medicine given, should also act on dynamic level and should be given internally to assist vital force to cure.Dr Hahnemann said, “ There are no diseases, only sick people”.Homoeopathy has no specific medicine for all patients of the same diagnosis, it treats the patient individually.In homoeopathy, External application on a diseased part is not applicable. Only homoeopathic medicine should be given internally only which is selected on the totalilty of symptoms.(Aph 194) 

As regards the cause of disease Dr. Hahnemann has classified causes into 3 categories-exciting cause(for acute disease), maintaining cause (causa occasionalis, which must be removed where it exists, for chornic disease) and fundamental cause (which is generally due to chronic miasm) (Aph.5, 7)  The Homoeopathic treatment consist of not only giving the indicated homoeopathic drugs, but to eliminate exiciting and maintaining cause.

For treating the patient, Patient’s Personal history like age, mode of living, diet, occupation, domestic circumstances, social relations etc are very important. It only help us to know to patient completely but also helps to know the cause of disease and many other factors which maintain the disease (exciting or maintaining cause) as well as for the selection of homoeopathic medicine (Aph 208) 

Representation of Urticaria related rubrics in Reprtories

• Kent repertory has 101 drugs under rubric– Skin, eruptions, urticaria⁴⁵
• Boger-Boeninghausen repertory has 75 drugs under rubric– Skin, eruptions, urticarious (nettle rash) ⁴⁶
• Boger’s Synoptic Key presented 11 drugs under– Skin, eruptions, urticarious, hives, wheals, etc.⁴⁷
• Boericke’s Repertory under urticaria (hives, nettle rash) has 54 drugs. ⁴⁸
• Knerr Repertory of Hering Guiding Symptoms has 61 drugs under– Skin eruptions, urticaria (nettle rash, hives) ⁴⁹
• Clarke in ‘The Prescriber’ under nettle rash (urticaria) has given 10 drugs. ⁵⁰

Symptomatic indications of some homeopathic medicines indicated for Urticaria like lesions:⁵¹

• Antimonium Crud– Dirty and unhealthy skin, Urticaria with red areola,   itching,concomitants-gastric disorder with white coated tongue <eve,heat washing >open air
• Antipyrinum–  Rash, erythema or urticaria, with troublesome itching, chiefly between fingers. Irregular rounded pimples lying close together, in some places confluent, forming patches, between which skin was normal, giving a marbled appearance, lasted five days, turned brownish and desquamated slightly.       Eruption thickest on body and extremities, extensor more covered than flexor surfaces.  Eruptions begins on face and arms, last on legs.  Scarlet macular eruption⁵²
• Apis Mel – Urticaria  during fever,sore,sensitive with burning pain.
• < heat,pressure,touch, >open air,bathing ,cold air
• Arsenic Album -Urticaria with burning, restlessness and intense thirst   <midnight,midday >heat,warm drinks 
• Bovista–Urticaria on excitement with rheumatic lameness, ,palpitation and diarrhea. < on waking up in the morning ,bathing
• Dulcamara -Urticaria-pruritis < at night when weather changes from warm to cool. > external warmth Itching and burning after scratching
• Chloralum Hydratum -Urticaria-erythema,intense itching <spirituous liquors,hot drinks,chill >warmth 
• Psorinum -Urticaria after every exertion <chanes if weather,from cold, >heat,summer
• Rhus.tox -Urticaria red,intense itching <cold,wet rainy weather,after rainj,night,>warmth,dry weather 
• Copaiva officinalis-Chronic urticaria in children,hives with fever and constipation 
• Astacus fluviatilis -Chronic urticaria with nettle rash on whole body with itching 
• Fragaria- Swelling of whole body due to urticaria
• Belladonna– Urticarial rash is attended by severe headache with redness of face <touch,noise,lying down
• Caladium– Urticaria alternating with asthma –<motion >safter weat
• Urtica urens– Urticaria alternating with Rheumatism,burning heat with formication,violent itching,consequences of suppressed urticaria  <water,touch
• Bombyx processonea– Itching of the whole body

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