DERMOGRAPHISM Dermatographic urticaria (also known dermographism, dermatographism or "skin writing is a skin disorder seen in 45% of the population

and is one of the most common types of physical urticaria. It is most common in young adults, ages 20-30. SYMPTOMS Typical red, itchy, linear wheals are evoked when the skin is stroked, rubbed, scratched, and sometimes even slapped. Overheating, stress and anxiety usually aggravate symptoms. . 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 (edema) termed the triple response of Lewis. MECHANISM The symptoms are thought to be caused by mast cells in the surface of the skin releasing histamines without the presence of antigens, due to the presence of a weak membrane surrounding the mast cells. This weak membrane easily and rapidly breaks down under physical pressure causing an allergic-like reaction, in general a red wheal(welt) to appear on the skin. In a normal case, the swelling will reduce itself with no treatment within 1530 minutes, but, in extreme cases, itchy red wheals may last anywhere from a few hours to days. CAUSES Symptoms can be induced by periods of stress, tight or abrasive clothing, watches, glasses, heat, cold, or anything that causes stress to the skin or the patient. In some cases, dermographism may occur after some bacterial and fungal infections, scabies, parasitosis, and after treatment with penicillin. DIAGNOSIS Generally, diagnosis involves a simple stroking of the skin with moderate pressure from the thumbnail, pen head or other kind of blunt object. TREATMENT Dermographism can be treated by antihistamines, which prevent histamine from causing the reaction. Ultraviolet B radiation may be effective for patients unresponsive to antihistamines. Frequent anecdotal evidence suggests taking in small amounts of alcohol may help with the itching, or temporary cause the inflammation/welts to subside. Acupuncture and Chinese herbs have long been used to treat urticaria in the Asian world..

COLD URTICARIA Cold urticaria (essentially meaning "cold hives") is an allergy where hives (urticaria) or large red welts form on the skin after exposure to a cold stimulus. It accounts for about 3% of physical urticaria. The disease is classified as chronic when hives appear for longer than 6 weeks; they can last for life, though their course is often unpredictable. The acquired form is most likely to occur between ages 1825. SYMPTOMS The welts are usually itchy and often the hands and feet will become itchy and swollen as well. Also a burning sensation occurs.Hives vary in size from about the size of 7 mm diam to as 27 mm diam. or larger. Systemic symptoms can be respiratory ( laryngeal angioedema, tongue or pharyngeal swelling, wheezing), vascular ( hypotension, tachycardia), gastrointestinal ( hyperacidity, nausea, diarrhea), or neurological( disorientation,headache).

MECHANISM The hives are a histamine reaction in response to cold stimuli. Hives result from increased permeability of capillaries which allow fluid to flow out into the surrounding tissue which is the epidermis. CAUSES Cold weather: Exposure to cold or cool air for more than a few minutes can trigger a reaction. Sweat: A reaction may even occur on a warm day when there is sweat on the skin. If there is a breeze it will rapidly cool the skin and create hives. Cold/Cool IV Lines: While in the hospital, inserting IV lines that have been refrigerated or are cool into individuals who are allergic to cold temperature can/may result in pain within the limb the IV is placed and a line of hives may appear . Swimming: Swimming can be especially dangerous as the rapid heart rate combined with the onset of hives can lead to hypotension. Air Conditioning: Entering a cool building during a summer day can result in an allergic reaction to exposed areas of skin, congestion from breathing the cool air and possibly feeling fatigued. Cold Foods/Drinks: Eating or drinking cold or cool substances such as ice cream or even iced tea may result in the individuals tongue and surrounding tissues swelling. Cool/Cold Surfaces: Sitting on sidewalks which are cool, will result in hives forming on the area which had contact with the cool surfaces.

Restriction of Blood Flow: Typing or other activities which tense muscles and reduce blood flow can cool the body parts enough to cause itching and hives. In 1-5 % of patients, cold urticaria may precede some diseases by several years: hepatitis C, infectious mononucleosis, Mycoplasma infection, autoimmune diseases, myeloma. DIAGNOSIS Diagnosis is typically obtained by an allergist performing a cold test. During the cold test, a piece of ice is held against the forearm, typically for 23 minutes. A positive result is a specific looking mark of raised red hives. The hives may be the shape of the ice, or it may radiate from the contact area of the ice. TREATMENT The most important treatment is to stay warm. Allergy medications containing antihistamines such as Claritin may be taken orally to prevent and relieve some of the hives. There has also been evidence to show that cold urticaria has been linked to a gluten intolerance, and gluten free diets have helped some CU sufferers. Cold hives can result in a potentially serious, or even fatal, systemic reaction (anaphylactic shock). People with cold hives may have to carry an injectable form of epinephrine (like Epi-pen or Twinject) for use in the event of a serious reaction.

Bibliography
Robert R. Rich, MD, Thomas A. Fleisher, MD, William T. Shearer, MD, PhD, Harry W. Schroeder, II, MD, PhD, Anthony J. Frew and Cornelia M. Weyand, 2008, Clinical Immunology Principles and Practice, Mosby Publishing

http://dermnetnz.org/reactions/cold-urticaria.html http://images.google.com/ http://en.wikipedia.org/wiki/Cold_urticaria http://en.wikipedia.org/wiki/Dermatographic_urticaria http://www.dermaamin.com/site/atlas-of-dermatology/4-d/334-dermagraphism------.html http://www.si.mahidol.ac.th/th/publication/2006/Vol89_No7_992.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794966/?tool=pmcentrez