Urticaria and its homoeopathic management

Dr Prathibha K

ABSTRACT
Urticaria is a common skin condition that, though rarely fatal, can seriously impair a patient’s quality of life. Urticaria is caused by cutaneous mast cell activation and degranulation disease triggered by numerous stimuli. The condition is defined as chronic if it persists for >6 weeks. Self-remission is common in acute Urticaria, but in chronic cases less than half of patients achieve remission within 1 year.¹

INTRODUCTION: The term Urticaria is defined as a transient eruption of circumscribed oedematous and usually itchy swellings of the dermis. The other names given are nettle rash, hives or wheals. These lesions last for a few hours but not exceeding 48 hours. The term angioneurotic oedema denotes similar but larger swellings of the deep dermal, sub-cutaneous and sub mucosal tissues. The other names are angioedema, giant Urticaria and Quinke′s oedema.²

Pathogenesis: The skin lesions of Urticaria disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis, and resulting in an oedema which persists until the interstitial fluid is absorbed into the surrounding cells.

The skin lesions of Urticaria disease are caused by an inflammatory reaction in the skin, causing leakage of capillaries in the dermis, and resulting in an oedema which persists until the interstitial fluid is absorbed into the surrounding cells.¹

Classification:

• Acute spontaneous Urticaria
• It lasts <6 weeks.
• Chronic spontaneous Urticaria (CSU)
• It recurs at least twice a week and lasts >6 weeks [3].
• Physical Urticaria (chronic inducible Urticaria)
• It emerges due to etiological factors as dermographism, cold, hot, vibration, pressure, and solar factors. It constitutes 20–30% of chronic Urticaria.

Episodic chronic Urticaria
It lasts >6 weeks but recurs <2 times per week .It should be kept in mind that CSU and physical Urticaria can be seen together. CSU is most commonly associated with dermatographic Urticaria and late pressure Urticaria.

Dermatographic urticaria: (also known as dermatographism or skin writing) is marked by the appearance of wheals or welts on the skin as a result of scratching or firm stroking of the skin. Seen in 4-5% of the population it is one of the most common types of urticaria, in which the skin becomes raised and inflamed when stroked, scratched, rubbed and disappears within 30 mints.

Pressure or delayed pressure: The type of urticaria can occur right away, precisely after a pressure stimulus or as a deferred response to sustained pressure being enforced to the skin. In the deferred form, the hives only appear after about six hours from the initial application of pressure to the skin. The hives may last from eight hours to three days.

Cholinergic or stress urticaria:  this form of urticaria is fairly widespread and occurs after exercise, sweating, stress, or any activity leading to warming of the core body temperature, such as warm or hot baths or showers. In severe cases, hundreds of tiny, red, itchy spots appear on the skin. The red spots manifest rather quickly and remain for about 60 to 90 minutes

Cold induced urticaria:  the cold type is caused by exposure of the skin to extreme cold, damp and windy conditions, it occurs in two forms. The common form of cold urticaria demonstrates itself with the rapid onset of hives on the face, neck, or hands after exposure to cold. The rare form is hereditary and becomes evident as hives all over the body 9 to 18 hours after cold exposure.

Water induced urticaria: this type of urticaria is also termed rare ,and occurs upon contact  with water. The response is not temperature dependent and the skin appears similar to cholinergic form of the disease. The appearance of hives is within one to 15 mints of contact with the water, and can last from 10 mints to two hours.

Solar urticaria: this form of disease occurs on areas of the skin exposed to the sun, the condition becomes evident within minutes of exposure. After the is no longer exposed to the sun, though the condition starts to weaken within a few minutes to few hours and hardly ever lasts longer than 24 hours.

Heat induced urticaria: This rare form of urticaria is triggered by application of heat on the skin. Hives begin to appear within two or five mints on the area of skin exposed to heat.

Aetiology:
Many factors may be responsible in the aetiology of the disease. Often, encountered factors include:

1. Medications: Any drug may cause Urticaria. However, the most commonly encountered ones are penicillin, aspirin, non-steroidal anti-inflammatory drugs, sulphonamides, thiazide diuretics, oral contraceptives, angiotensin-converting enzyme inhibitors, vitamins, codeine, morphine, curare and its derivatives, synthetic adrenocorticotropic hormone, and radio contrast substances. It may manifest from 1–2 h to 15 days after oral intake.
2. Foods: Foods often encountered as causes of Urticaria include nuts, eggs, fish, seafood, chocolate, meat, cow’s milk, fruits (citrus fruits, grapes, plums, pineapples, bananas, apples, and strawberries), vegetables (tomatoes, garlic, onions, peas, beans, and carrots), mushrooms, fermented foods, spices, and spirits. Preservatives such as benzoic acid derivatives, and salicylates and food dyes are also important causative factors. Urticaria is usually seen 1–2 h after ingestion. Food-related urticarial rashes are more common in children.
3. Respiratory allergens: Pollen, mold spores, mites, animal dandruff, and hairs may cause Urticaria when taken through the respiratory tract. Smoking is also an important factor since it contains many chemicals and can worsen the Urticaria, hives should be advised to stop smoking.
4. Infections: Respiratory infections such as sinusitis, tonsillitis, dental abscesses, urinary tract infections, hepatitis, infectious mononucleosis, and parasites may cause Urticaria.
5. Contact Urticaria: Latex, cosmetics, and chemicals may cause urticaria by contact.
6. Insect bites: They should be questioned, especially in children.
7. Psychogenic factors: Reasons such as stress, sadness, and depression may aggravate the pre-existing urticaria and also induce urticaria.
8. Systemic diseases: They may cause especially chronic urticaria. The presence of thyroid diseases and rheumatic diseases such as systemic lupus erythematous, lymphoma, leukaemia, and carcinomas may be investigated as required. It should be noted that urticaria may occur also in pregnant women.
9. Physical factors: Urticaria may develop due to external factors such as pressure, hot, cold, and dermographism. Urticaria secondary to pressure generally manifests an average of 3–4 h after exposure to pressure. Therefore, they are termed as delayed pressure urticaria.
10. Hereditary: Hereditary urticaria is seen in types of urticaria as angioedema and familial cold urticaria.
11. Idiopathic urticaria without any known cause may be also seen.³

Clinical Manifestations
The urticarial plaque has three characteristics as characteristic redness, blistering, and itching. Sometimes, a burning sensation may accompany. Lesions can occur anywhere in the body and recover in approximately 2–3 hrs. , without leaving a trace. This spontaneous recovery can sometimes last up to 1 day. In angioedema, especially in areas such as eyelid and lip mucosae, there is a sudden-onset skin swelling. Pain and burning sensation may be at the forefront rather than pruritus. The lesions regress spontaneously in about 72hrs.

Urticaria occasionally may be associated with a few systemic symptoms such as vomiting, giddiness, malaise, headache, abdominal pain, diarrhoea, dizziness and rarely anaphylaxis. Premenstrual exacerbation may be noticed in some.^1,2

Diagnosis

• Clinical evaluation
• Skin prick test³

Investigations

Establishing the cause of urticaria is difficult. In about 70% of cases, no clear-cut reason can be detected.

The following may be appropriate:

• Full blood count.
• Erythrocyte sedimentation rate (ESR).
• Urea and Electrolytes, Thyroid and LFT, Iron Studies.
• Total IgE and Specific IgE to Possible Allergens.
• Antinuclear Factor⁴

Differential diagnosis

• Atopic dermatitis (eczema)
• Maculopapular drug eruptions
• Contact dermatitis, insect bites,
• Erythema multiforme,
• Pityriasis rosea.³

INDICATIONS OF SOME HOMOEOPATHIC MEDICINES^5,6

APIS MELLIFICA:

• Hives burning, stinging and itching.
• Rosy red, sensitive sore skin, Stinging pains.
• Urticaria like bee stings, or stings from other insects, with intolerable itching at night, large urticaria.

URTICA URENS:

• Urticaria burning heat with formication, violent itching.
• Angioneurotic oedema
• Hives with rheumatism, after shellfish, with pinworms.
• Itching raised , red blotches

PULSATILLA NIGRICANS:

• Skin itches on being heated
• Urticaria with rich food, with diarrhoea.
• Urticaria from delayed menses, worse undressing
• Urticaria in summer.

ANTIMONIUM CRUDUM:

• Thick hard honey coloured scabs
• Urticaria, white with red areola, itching fearfully.
• Itching of the skin, feels sore when scratched.

RHUS TOX:

• Urticaria from getting wet with rheumatism
• Urticaria during chills and fever
• Red swollen intense itching.

NATRUM MURATICUM:

• Obstinate cases with constipation and earthy complexion

RADIUM BROMATUM:

• Itching of skin all over the body, burning of skin as if on fire.
• Burning swelling and redness.

DULCAMARA:

• Urticaria red spots, brought on by exposure or sore stomach.
• Nettle rash over whole body with violent itching.

ARSENICUM ALBUM:

• Skin symptoms alternate with asthma or internal disorders.
• Itching, burning, swellings oedema.

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 eruption.

CHLORALUM HYDRATUM :

• Urticaria-erythema, intense itching <spirituous liquors, hot drinks, chill >warmth.

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

Studies done in homoeopathy
A case series of five patients suffering from chronic urticaria having erythematous       lesions, intense itching, redness and swelling treated at the Dermatology outpatient department of Dr D. P. Rastogi Central Research Institute for Homoeopathy, Noida, and Uttar Pradesh, India. The patients were prescribed indicated constitutional Homoeopathic medicines. Changes in haematological and serological tests, Measure Yourself Medical Outcome Profile 2 and Urticaria Activity Score summed over 7 days at baseline and at the end of treatment showed reasonable improvement in disease as well as in the quality of life. Homoeopathic medicines such as Apis mellifica, Calcarea carbonica, Rumex crispus, Pulsatilla and Histamine were found useful. Urticaria with burning and restlessness.⁷

Homoeopathic medicines have potential to improve QoL of CU patients by reducing pruritus, intensity of wheals, swelling, nervousness, and improve sleep, mood and concentration. Further studies with more sample size are desirable.⁸

Keywords: Chronic urticaria quality of life questionnaire, Chronic urticaria, Homoeopathy, Quality of life

Homoeopathic medicines reduce both the intensity and frequency of attacks of urticaria and help in improving the quality of life of patients. Individualised homoeopathic treatment is associated with significant alleviation of urticaria symptoms, thus also leading to reduction in the use of conventional anti-allergic medication⁹

Representation of Urticaria related rubrics in Repertories

1. Kent repertory has 101 drugs under rubric– Skin, eruptions, urticaria¹⁰
2. Boger’s Synoptic Key presented 11 drugs under– Skin, eruptions, urticarious, hives, wheals, etc.¹¹
3. Boger-Boeninghausen repertory has 75 drugs under rubric– Skin, eruptions, urticarious (nettle rash) ¹²
4. Boericke’s Repertory under urticaria (hives, nettle rash) has 54 drugs.¹³
5. Clarke in ‘The Prescriber’ under nettle rash (urticaria) has given 10 drugs.¹⁴
6. Knerr Repertory of  Hering Guiding Symptoms has 61 drugs under– Skin eruptions, urticaria (nettle rash, hives) ¹⁵

Some important rubrics¹⁶

• ERUPTIONS urticaria upper limbs white Natrum -muraticum
• ERUPTIONS urticaria shoulder Lachesis
• ERUPTIONS urticaria  upper  arm,  right arum – dracontium
• ERUPTIONS urticaria elbow aranea
• ERUPTIONS  urticaria  forearm  morning china officinalis
• ERUPTIONS urticaria forearm evening Lycopodium
• ERUPTIONS urticaria forearm heat, during caladiumium
• ERUPTIONS   urticaria   hand   morning china officinalis
• ERUPTIONS    urticaria    hand    red    after   rubbing Natrum-muraticum
• ERUPTIONS  urticaria  hand  back  of  hands  become cool, when thuja
• ERUPTIONS   urticaria   fingers   cold,   on   becoming thuja
• ERUPTIONS urticaria knee zincum metallicum
• ERUPTIONS  urticaria  knee  hollow  of zincum metallicum
• ERUPTIONS urticaria leg calf carbo-vegetabilis
• ERUPTIONS urticaria ankle Natrum-muraticum
• EXTREMITY PAINGENERAL    rheumatic    alternating with    urticaria urtica–urens
• LOCALIZATION   Lower   limbs   rheumatic   urticaria, with urtica –urens
• SKINERUPTIONS blotches red urticaria Apis
• ERUPTIONS blotches white urticaria, like Apis
• ERUPTIONS urticaria morning waking, on bovista
• ERUPTIONS urticaria afternoon chloralum
• ERUPTIONS urticaria air change of, from Apis
• ERUPTIONS urticaria air open amel. Calcarea
• ERUPTIONS urticaria alcoholic drinks, after chloralum
• ERUPTIONS    urticaria    alternating    with cramps arsenic
• ERUPTIONS urticaria alternating with croup arsenic
• ERUPTIONS  urticaria  alternating  with  rheumatism urtica –urens
• ERUPTIONS urticaria annual urtica –urens
• ERUPTIONS  urticaria  appearing  and  disappearing suddenly, with internal coldness antipyrine
• ERUPTIONS  urticaria  ascarides,  with urtica–urens
• ERUPTIONS urticaria asthmatic troubles, in apis
• ERUPTIONS    urticaria    bathing,    after   cold    agg.    calcarea-phos
• ERUPTIONS   urticaria   bathing,   after cold   amel.    Pulsatilla
• ERUPTIONS   urticaria   bleeding   after   scratching coca
• ERUPTIONS   urticaria   chill   before hepar sulphuricum
• ERUPTIONS  urticaria  chill  sudden  exposure,  from chloralum
• ERUPTIONS  urticaria  chronic  recurring hepar sulphuricum
• ERUPTIONS   urticaria   clothing,   from   pressure   of  medorrihnum
• ERUPTIONS  urticaria  cold  bath,  after calcarea-phos
• ERUPTIONS urticaria coldness, with internal pinus–sylvestris
• ERUPTIONS urticaria colds agg.   Dulcamara
• ERUPTIONS urticaria constipation, with copaiva
• ERUPTIONS urticaria drinking agg. Cold belladonna
• ERUPTIONS urticaria drinking agg. hot. chloralum
• ERUPTIONS urticaria erosion on toes, with sulphur
• ERUPTIONS urticaria fever suppressed, from elaterium
• ERUPTIONS   urticaria   food,   from   fruit,   pork   or buck wheat Pulsatilla
• ERUPTIONS    urticaria    food,    from    strawberries fragaria
• ERUPTIONS urticaria food, from rich Pulsatilla
• ERUPTIONS urticaria insect bites, from Apis
• ERUPTIONS urticaria lying amel. urtica –urens
• ERUPTIONS   urticaria   malaria,   from   suppressed    elaterium
• ERUPTIONS urticaria meat, after      antimonium-crudum
• ERUPTIONS urticaria menses during profuse bovista
• ERUPTIONS urticaria menses after kreosote
• ERUPTIONS urticaria menses delayed, from Pulsatilla
• ERUPTIONS urticaria nausea before sanguinaria
• ERUPTIONS urticaria nausea with sanguinaria
• ERUPTIONS urticaria neuralgia, after mezerium
• ERUPTIONS urticaria overexertion, from antimonium–crudum
• ERUPTIONS urticaria palpitation, with bovista
• ERUPTIONS urticaria periodical, every year urtica –urens
• ERUPTIONS urticaria perspiration during      Rhus-toxicodendron
• ERUPTIONS urticaria perspiration after      Apis
• ERUPTIONS    urticaria    petechial    disturbance  or erysipelatous eruption, with fragaria
• ERUPTIONS urticaria pinworm, with urtica –urens
• ERUPTIONS urticaria receding strophanthus
• ERUPTIONS    urticaria    recurring hepar sulphuricum
• ERUPTIONS   urticaria   respiration,   with   difficult Apis
• ERUPTIONS urticaria rubbing amel.    Elaterium
• ERUPTIONS   urticaria   Spring,   every Rhus-toxicodendron
• ERUPTIONS urticaria sudden violent onset, syncope, with camphor
• ERUPTIONS urticaria suppression of, agg. urtica–urens
• ERUPTIONS urticaria thinking of it oxalic-acid

Conclusion
Homoeopathy offers excellent treatment for urticaria. In a holistic approach to the homoeopathic system of medicine, skin diseases are not considered local diseases. Treatment of urticaria is not only dependent on a character but also on periods and condition aggravation, generals & particulars considered. The above therapeutics medicines are used frequently in urticaria with the best results. Other individualized homoeopathic medicines can also offer significant result in urticaria.

REFERENCES:

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15. Knerr CB. Repertory of Hering’s Guiding Symptoms of our Materia Medica. New Delhi, B. Jain Publishers, 2002.
16. MuniP,  PatelG,  PopatG,  ShahP. Repertory  Of  Urticaria,  Rubrics  Having Single  Remedy. Natl  J Integr Res  Med  2016; 7(2): 139-142

Dr Prathibha K
PG Scholar, Department of Practice of Medicine
Government Homoeopathic Medical College & Hospital, Bangalore.
Dr. Siddhaiah Puranik Road, Basaveshwar Nagar, Bengaluru, 560079
Under the Guidance of Dr. Veerabhadrappa.C
Associate Professor and PG guide Department of Practice of Medicine.