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Delayed pressure urticaria (DPU) is a subset of chronic inducible urticaria. It is characterized by the formation of wheals anytime between 30 minutes and 24 hours after stimulus exposure of localized pressure application. In this case report, we discuss a military flight crew member with no significant past medical history who developed DPU following rapid decompression in an altitude chamber. The chamber training included an uneventful ascent to 45,000 feet, higher than he had been previously, and a rapid decompression. About 16 hours later, he developed pruritic swelling of his hands and feet, along with diffuse deep nodular swelling, erythematous plaques, and erythematous nodules. His DPU was refractory to monotherapy treatment with antihistamines, and he continued to develop lesions in weight-bearing areas. Control of symptoms was achieved through combination treatment of a second-generation antihistamine, a leukotriene receptor antagonist, and an immunosuppressant (cyclosporine). His waiver to return to flight status was denied while on cyclosporine. He was transitioned to a monoclonal antibody that binds free immunoglobin E (omalizumab) with resolution of symptoms and was cleared to return to active duty., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

The use of dock leaves to ease the discomfort of nettle stings is a well-known folk remedy in the British Isles, yet has never been tested in a clinical trial. A group of Emergency Department doctors designed and conducted the Nettle-induced Urticaria Treatment Study (NUTS) as a research training and team-building exercise to address this gap in the Emergency Medicine evidence base., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Urticaria multiforme is an uncommon presentation of acute urticaria. It most commonly affects children and most often occurs secondary to an underlying viral infection. We performed a retrospective review of a cohort of Asian children with urticaria multiforme and reviewed the literature on the condition., Methods: We retrospectively reviewed the clinical notes of children and adolescents less than 16 years of age, diagnosed with urticaria multiforme at our tertiary paediatric hospital between January 2017 and December 2022. Data collected and analysed included age, gender, initial diagnosis, antecedent symptoms, recent immunisations and medications, results of diagnostic tests, treatment and outcome., Results: A total of 20 children were identified, with median age of diagnosis of 1.9 years, with most patients (79%) 7 years of age or younger. Viral infections were the commonest triggers. The most common referring diagnoses were erythema multiforme and Stevens-Johnson syndrome. Common antecedent or concomitant symptoms were fever and upper respiratory symptoms. Blood investigations were generally unremarkable except for mildly increased white cell counts and other markers of infection. Outcomes were good in all patients, with resolution of symptoms within 6 weeks without sequelae., Conclusion: Urticaria multiforme is an uncommon presentation of acute urticaria. Despite its striking appearance, it is generally a benign, self-limiting condition. Extensive investigations are usually not required and management is largely supportive., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Competing Interests: Disclosures Dr Welsh and Dr Schuldt have no conflicts of interest to report.

Aquagenic urticaria, a rare variant of chronic-inducible urticaria, is triggered by direct contact with water. It is distinguished by its characteristic small wheals accompanied by a halo of erythema from other forms of urticaria. It typically manifests with a delayed diagnosis due to the atypical trigger and the potential for diverse clinical presentations. We present a case of aquagenic urticaria in an adolescent male that demonstrates the need for accurate differential diagnosis and appropriate management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: This article describes a teenage patient who was referred to a pediatric endocrinologist after her workup for recurring urticaria revealed a suppressed thyroid-stimulating hormone level and positive microsomal thyroid peroxidase antibodies. The patient's laboratory results revealed an autoimmune cause for the urticaria as a result of new-onset autoimmune thyroid disease., (Copyright © 2024 American Academy of Physician Associates.)

Chronic inducible urticaria (CIndU) is characterized by the appearance of hives (urticaria) and/or angioedema in response to specific triggers or stimuli. For accurate diagnosis, anamnesis-driven specific, and if available, standardized trigger testings, as well as patient reported outcomes, should be applied. The currently recommended treatment algorithm is the same as for chronic spontaneous urticaria but is largely off-label for CIndU. New, and possibly more disease-specific, treatment options are needed for CIndU patients, who are often severely impacted by their disease. Several clinical trials are currently ongoing., Competing Interests: Disclosure S. Altrichter is or recently was a speaker and/or advisor for and/or has received research funding from AstraZeneca, United Kingdom, Allakos, BioCryst, United States, Blueprint, GSK, LEO Pharma, Lilly, LEO Pharma, Denmark, Moxie, Novartis, Switzerland, Phavaris, Takeda, Thermo Fisher, United States and Sanofi, France. D. Ritzel has no potential conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Urticaria, also known as hives, is a common condition thought to affect up to 20% of individuals worldwide in their lifetime. This skin condition is characterized by the appearance of pruritic, erythematous papules or plaques with superficial swelling of the dermis. The major complaint is the symptom of pruritus. Angioedema, which involves a deeper swelling of dermal or mucosal tissues, may accompany urticaria. Urticaria can be classified by both time course of symptoms and the underlying etiology., Competing Interests: Disclosure E.T. Oliver: Grant Support: National Institutes of Health, United States (K23AI139394), Robert Meyerhoff Professorship Advisory Board/Consultant: Novartis, Regeneron/Sanofi. S.S. Saini: Grant Support: Novartis, Switzerland, Sanofi, France, Regeneron, United States, National Institutes of Health, United States, Allakos, Escient Advisory Board/Consultant: Allakos, Granular Therapeutics, Novartis, Aquestive, Regeneron, Escient, Evommune, Innate, Celltrion, Sanofi., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Chronic urticaria is an inflammatory skin disorder defined by the presence of evanescent erythematous pruritic wheals, angioedema, or both. While treatment guidelines are continuing to become more clearly defined, there is still a gap in the medical literature surrounding chronic spontaneous urticaria (CSU) treatment in vulnerable populations such as children (aged 0-18 years), pregnant women, and the elderly (aged >65 years). The purpose of this review is to provide an update on CSU in each of these special population categories by defining prevalence, identifying diagnostic considerations, and exploring current and future management options., Competing Interests: Disclosure M. Robson: none; J.S. Bernstein: none; J.A. Bernstein: Sanofi Regeneron, Novartis, Genentech, Astra Zeneca, Amgen, GSK, Celldex, Blueprint Medicine, Jasper pharmaceuticals, Allakos., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Urticarial vasculitis is a rare autoimmune disorder characterized by persistent edematous papules and plaques on the skin that last longer than 24 hours, often accompanied by systemic symptoms such as joint pain and fever. Unlike common urticaria, this condition involves inflammation of small blood vessels, leading to more severe and long-lasting skin lesions with a tendency to leave a bruiselike appearance. Diagnosis is challenging and may require a skin biopsy. Associated with underlying autoimmune diseases, treatment involves managing symptoms with medications such as antihistamines and corticosteroids, addressing the immune system's dysfunction, and treating any concurrent autoimmune conditions., Competing Interests: Disclosure The authors declare no competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Acute urticaria is a prevalent inflammatory dermatosis characterized by fulminant wheals, often accompanied by severe pruritis. It may also cause nausea, vomiting, and abdominal pain. Numerous studies have substantiated the pivotal involvement of double-stranded DNA (dsDNA) in autoimmunity. However, the role of dsDNA in the pathogenesis of acute urticaria is unclear., Methods: We measured serum dsDNA levels in patients and controls. The relationship between dsDNA levels and environmental exposures (temperature, ultraviolet [UV] index, and season) was investigated by correlating disease onset dates with archived meteorological data. Finally, we used quantitative PCR to determine the expressions of genes encoding dsDNA receptors, single-stranded RNA (ssRNA) receptors, exosome formation, and type I interferon in the peripheral blood of patients and controls., Results: Serum dsDNA levels were significantly higher in patients with acute urticaria compared with controls (mean values 1.38 and 0.94 ng/ml, respectively, P < 0.001). dsDNA levels were higher in patients exposed to higher environmental temperatures and UV indices and were higher during the summer months. We also found that the expressions of genes encoding dsDNA receptors, ssRNA receptors, absent in melanoma factor 2 (AIM2)-related inflammatory factors, and interferon alpha were up-regulated in patients., Conclusions: We demonstrated that serum dsDNA levels are elevated in acute urticaria and are influenced by climatic factors such as temperature, ultraviolet index, and season. We also found that elevated dsDNA promotes the expression of AIM2-related factors and type I interferons. This study generates new hypotheses regarding the pathogenesis of acute urticaria and suggests novel therapeutic targets., (© 2024 the International Society of Dermatology.)

Purpose of Review: Chronic inducible urticaria (CIndU) is a group of long-persisting and challenging to manage diseases, characterized by recurrent wheals and angioedema induced by definite triggers. In this review, we address recent findings on CIndU pathogenesis, diagnosis as well as its treatment, and we discuss novel potential targets that may lead to the development of more effective therapies for CIndU patients., Recent Advances: Meaningful advances in the understanding of its pathogenesis have been reported in the last decades. Novel CIndU-specific patient-reported outcome measures enable a closer and better evaluation of patients. CIndU is a hard-to-treat disease that highly impairs quality of life (QoL) of affected patients. Provocation tests allow to diagnose CIndU subtypes. The only licensed and recommended treatment for CIndU are second generation non-sedating H1-antihistamines, which lack efficacy in many cases. Omalizumab off-label use has been assessed in all types of CIndU with overall good outcomes. Promising emerging therapies currently assessed in chronic spontaneous urticaria are paving the path for novel treatments for CIndU., (© 2024. The Author(s).)

Competing Interests: Disclosure J. Stitt reports receiving grant support from Genentech.

Dermographism is a common subtype of chronic urticaria. It generally manifests as a linear wheal after scratching or friction, with or without angioedema. The pathophysiology is not clear, but currently, we believe that the stimulation of the skin by mechanical stress leads to the activation of mast cells, which provoke the release of histamine and pro-inflammatory mediators, ultimately forming wheal along the stressed area. The gold standard for diagnosis is a medical history and provocation test or dermatographic test. As one of the subtypes of chronic urticaria, the Urticaria Control Test (UCT), Chronic Urticaria Quality of Life questionnaire (CU-Q2oL), and Dermatology Life Quality Index (DLQI) are also effective tools for evaluating disease control in dermographism patients. In addition to avoiding triggers, nonsedating H1 antihistamines are the first-line medications recommended by EAACI and other guidelines; for those who do not respond to standard doses, the recommended dosage can be increased up to 4 times. When necessary, the off-label use of omalizumab can be considered, and some drugs with potential therapeutic effects are still being explored. However, there is still a lack of biomarkers for predicting disease severity, efficacy, and prognosis. Here, we review what we know about dermographism and some points that need exploration in the future., (© 2024 the International Society of Dermatology.)

Urticaria and angioedema are caused by immunoglobulin E- and non-immunoglobulin E-mediated release of histamine and other inflammatory mediators from mast cells and basophils. Diagnosis is made clinically, and anaphylaxis must be ruled out if urticaria or angioedema is present. A limited nonspecific laboratory workup should be considered unless elements of the history or physical examination suggest specific underlying conditions. The mainstay of treatment is avoidance of triggers when and if triggers are identified. The first-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Solar urticaria is a rare idiopathic photodermatosis. According to the current knowledge its pathogenesis is most likely based on an allergic type I reaction to an autoantigen activated by ultraviolet (UV) radiation or visible light. As many of the patients suffer from severe forms of the disease, it may therefore severely impair the quality of life of those affected. In contrast, polymorphous light eruption is a very common disease, which, according to the current data, can be interpreted as a type IV allergic reaction to a photoallergen induced by UV radiation. As the skin lesions heal despite continued sun exposure, the patients' quality of life is generally not significantly impaired. These two clinically and pathogenetically very different light dermatoses have shared diagnostics by means of light provocation and an important therapeutic option (light hardening). Herein, we present an overview of the clinical picture, pathogenesis, diagnosis and available treatment options for the above-mentioned diseases., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Hymenoptera stings can produce IgE-mediated reactions, toxic reactions, or atypical reactions, which are rare. Cold urticaria has been described among the cutaneous manifestations in the atypical ones, but there is only one case of chronic urticaria., Case Report: A 56-year-old female patient experienced palmoplantar pruritus and generalized urticaria 60 minutes after two vespid stings, requiring medical assistance and several cycles of home treatment with oral antihistamines and corticosteroids for resolution in 12 weeks. Allergological studies showed normal tryptase and primary sensitization to Polistes dominula venom. Given the patient's profession, venom immunotherapy was started with Polistes dominula 100% without recurrence of urticaria after its administration., Conclusions: We present a case of IgE-mediated systemic reaction followed by self-limited chronic urticaria, related chronologically to the same vespid sting trigger.

Purpose of Review: This paper explores how environmental factors influence allergic skin diseases, including atopic dermatitis (AD), contact dermatitis (CD), urticaria, angioedema, and reactions to drugs and insect bites., Recent Findings: Research indicates a significant impact of environmental elements on allergic skin diseases. High air pollution levels exacerbate symptoms, while climate change contributes to increased skin barrier dysfunction, particularly affecting AD. Allergen prevalence is influenced by climate and pollution. Irritants, like those in detergents and cosmetics, play a major role in CD. Plants also contribute, causing various skin reactions. Understanding the interplay between environmental factors and allergic skin diseases is crucial for effective management. Physicians must address these factors to support patient well-being and promote skin health amidst environmental changes., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Cutaneous adverse events after receiving a COVID-19 vaccine were identified. The disease activity of urticaria after a COVID-19 vaccine has never been explored in chronic urticaria patients., Objective: To evaluate disease activity of chronic urticaria after receiving a COVID-19 vaccine., Methods: A prospective cross-sectional study was conducted in chronic urticaria patients aged 18 or above who visited Siriraj Hospital between July and September 2021, and received the first and second dose of COVID-19 vaccine. The status prior to vaccination, including disease activity, disease control and disease severity was assessed by a urticaria activity score over seven days, urticaria control test, and modified medication score. The disease activity after vaccination was recorded., Results: A total of 130 patients with a mean age of 45.9 ± 14.7 were enrolled in this study. Adenoviral and inactivated vaccines were administered to 85 (65.4%) and 45 patients (34.6%), respectively. Exacerbation was reported in 20 cases (15.4%) after the first dose and 17 cases (13.1%) after the second dose. Nine patients (45%) reported exacerbation after both the first and second dose. The majority of patients only had wheal, while three patients reported wheal with angioedema. No anaphylaxis was reported. Factor predicting exacerbation was concurrent thyroid disease (aRR 2.78, p < 0.01)., Conclusions: Approximately 15% of chronic urticaria patients reported exacerbation after receiving a COVID-19 vaccination. No serious events were observed. Chronic urticaria patients should be vaccinated against COVID-19 after a discussion of the risk of disease flare-up.

The recent recognition of a syndrome of tick-acquired mammalian meat allergy has transformed the previously held view that mammalian meat is an uncommon allergen. The syndrome, mediated by IgE antibodies against the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal), can also involve reactions to visceral organs, dairy, gelatin and other products, including medications sourced from non-primate mammals. Thus, fittingly, this allergic disorder is now called the alpha-gal syndrome (AGS). The syndrome is strikingly regional, reflecting the important role of tick bites in sensitization, and is more common in demographic groups at risk of tick exposure. Reactions in AGS are delayed, often by 2-6 h after ingestion of mammalian meat. In addition to classic allergic symptomatology such as urticaria and anaphylaxis, AGS is increasingly recognized as a cause of isolated gastrointestinal morbidity and alpha-gal sensitization has also been linked with cardiovascular disease. The unusual link with tick bites may be explained by the fact that allergic cells and mediators are mobilized to the site of tick bites and play a role in resistance against ticks and tick-borne infections. IgE directed to alpha-gal is likely an incidental consequence of what is otherwise an adaptive immune strategy for host defense against endo- and ectoparasites, including ticks., (© 2024 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Cholinergic urticaria is a dermatological disease characterized by the presence of large patches of red skin and transient hives triggered by factors, such as exercise, sweating, and psychological tension. This skin problem is hypothesized to be attributed to a reduced expression of acetylcholinesterase (AChE), an enzyme responsible for hydrolyzing acetylcholine (ACh). Consequently, ACh is thought to the leak from sympathetic nerves to skin epidermis. The redundant ACh stimulates the mast cells to release histamine, triggering immune responses in skin. Here, the exposure of ultraviolet B in skin suppressed the expression of AChE in keratinocytes, both in in vivo and in vitro models. The decrease of the enzyme was resulted from a declined transcription of ACHE gene mediated by micro-RNAs, that is, miR-132 and miR-212. The levels of miR-132 and miR-212 were markedly induced by exposure to ultraviolet B, which subsequently suppressed the transcriptional rate of ACHE. In the presence of low level of AChE, the overflow ACh caused the pro-inflammatory responses in skin epidermis, including increased secretion of cytokines and COX-2. These findings suggest that ultraviolet B exposure is one of the factors contributing to cholinergic urticaria in skin., (© 2024 The Authors. The FASEB Journal published by Wiley Periodicals LLC on behalf of Federation of American Societies for Experimental Biology.)

Competing Interests: A. Le Seac'h déclare n'avoir aucun lien d'intérêts. E. Amsler déclare être salariée de Product life group; avoir participé à des interventions ponctuelles et avoir été prise en charge, à l'occasion de déplacements pour congrès, par Novartis et Sanofi. A. Soria déclare avoir participé à des interventions ponctuelles pour Novartis, Abbvie, Lilly, LEO Pharma, Pfizer, Sanofi et Bioprojet. Oratrice pour Novartis, Abbvie, Sanofi et LEO Pharma; et avoir été prise en charge, à l'occasion de déplacements pour congrès, par Sanofi.

The aim of this review is to present relevant trigger as well as augmentation factors that can induce or exacerbate urticaria on the basis of a current, PubMed-based literature search. In addition to a brief description of relevant influencing factors in acute and chronic inducible urticaria, the focus will be on chronic spontaneous urticaria. In particular, the aggravating role of medication, stress, food, psychological and metabolic comorbidities, infections and inflammation as well as hormonal processes will be discussed., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: Although acute urticaria (AU) and urticaria-like rash are commonly reported with COVID-19 infection, chronic spontaneous urticaria (CSU) triggered by COVID-19 is rare. The authors compared the features of COVID-19 infection-induced chronic CSU and AU to determine which patients' COVID-19 infection leads to CSU and possible indicators of chronicity., Methods: The authors retrieved the charts of patients diagnosed with AU or CSU following COVID-19 at the Urticaria Centers of Reference and Excellence and compared patients in terms of demographic characteristics, length of time between infection and onset of urticaria, duration of urticaria, COVID-19 disease severity, laboratory test results, vaccination, and treatment status., Results: A total of 92 patients were included in the study: 7 with CSU following COVID-19 and 85 with AU after COVID-19. The mean duration of urticaria for CSU and AU following COVID-19 was 13.0 ± 6.0 months and 7.1 ± 3.4 days, respectively. The average time between COVID-19 and the start of urticaria was longer in the CSU group (20.7 ± 3.9 days vs 4.5 ± 2.8 days, respectively; P = .000). No between-group differences were found for any other parameters., Conclusions: The onset of urticaria more than 2 weeks after COVID-19 infection may serve as an indicator for urticaria chronicity beyond 6 weeks and may help physicians predict the possible course of urticaria associated with COVID-19 infection. The relevance of basopenia and eosinopenia needs to be determined., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Urticaria in infants can cause significant anxiety in parents, especially if a trigger cannot be identified. In a retrospective study of 246 infants seen for urticaria of unknown etiology at Boston Children's Hospital, 88.2% had resolution of urticaria within 6 weeks. The etiology of urticaria was ultimately established in 62.6% (72/115) of acute urticaria and 12.5% (2/16) of chronic urticaria cases with follow-up data. Pediatric healthcare providers can counsel families that while etiology of urticaria is never determined in over 40% of infants, symptoms are most likely to resolve spontaneously., (© 2024 Wiley Periodicals LLC.)

COVID-19 is an infectious disease caused by SARS-CoV-2 that is characterized by respiratory symptoms, fever, and chills.[1] While these systemic symptoms are widely known and well understood, there have also been reports of dermatological manifestations in patients with COVID-19. These manifestations include chilblain-like lesions, maculopapular lesions, urticarial lesions, necrosis, and other varicella-like exanthems.[2] The pathogenesis of these lesions are not well understood, but the procoagulant and pro-inflammatory state induced by COVID-19 infections may be contributing to varied cutaneous manifestations.[3] Drug interactions and concurrent hypersensitivity reactions have also been postulated.[4] This review aims to compile and analyze various retrospective studies and case reports to summarize the clinical presentation of dermatological lesions associated with COVID-19 infections and suggest further areas of research., Competing Interests: The authors have no conflicts of interest to declare.

Several adverse cutaneous reactions have been reported in the literature after SARS-CoV-2 vaccination with emerging reports on chronic spontaneous urticaria (CSU). However, there is little literature of chronic urticaria after COVID-19 boosters in a military population and the impact on operational readiness. We present a retrospective case series of CSU following Moderna COVID-19 booster vaccinations at the US Naval Academy (USNA). Demographics, clinical features, and impact on readiness were evaluated. Forty-nine students from the USNA were evaluated for urticaria after their third COVID-19 booster vaccination. Seventeen individuals were diagnosed with CSU. The median age was 20 years and predominantly male; the median time interval between vaccination and the onset of urticaria was 11 days. Out of 13 referred to Allergy, 7 patients had CU index performed and 2 were positive. Four patients received a second booster vaccination subsequently and did not have any exacerbation of symptoms. Symptoms were controlled with antihistamines, and none required immunomodulator or immunosuppressive therapies. All students were able to complete their commissioning, and none were referred for a medical board. In this series, USNA students who developed CSU after the mRNA COVID-19 Moderna booster vaccine did not have limitations from commissioning, duty status, or issues with subsequent COVID-19 vaccinations., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Competing Interests: Conflicts of interest A.S. declares the following conflicts of interest: consulting and speaker for Novartis and Sanofi. A.D.T. declares the following conflicts of interest: principal investigator, speaker and consulting for Novartis and a partial grant from Novartis for a research study. The remaining authors declare they have no conflicts of interest.