Successful Treatment of Disabling Cholinergic Urticaria

Military Medicine, Feb 2008 by Feinberg, Jeff H, Toner, Charles B

ABSTRACT A 22-year-old African American U.S. sailor presented with an intermittent pruritic eruption precipitated by mild activity for the last 2 years. She developed an extremely pruritic papular rash that would quickly coalesce into larger wheals following any exercise, light activity such as vacuuming, or taking hot showers. This condition had been getting progressively worse, preventing her from successfully completing her physical readiness test and other required physical training for the last 2 years. Previous treatment with antihistamines and steroids had failed to control her symptoms. She was diagnosed with cholinergic urticaria, successfully controlled with a combination of cetirizine, montelukast, and propanolol. She has since been returned to full military duty and is able to exercise regularly.

CASE REPORT

A 22-year-old African American female in the U.S. Navy presented with a 2-year history of exercise-associated rash. Almost immediately after starting exercise, she would develop extremely pruritic papules beginning on her arms that would quickly increase in both number and size, spreading to her trunk and extremities. She also had occasional involvement of her central face and postauricular neck. Although symptoms had been present for 2 years, they had increased significantiy 15 months before presentation, at which time she had noticed she had stopped sweating. At the time of presentation, she could not tolerate even light activity such as vacuuming or housecleaning without eliciting an outbreak of the rash. hot showers would provoke a similar response. She denied associated chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, wheezing, and lightheadedness with her episodes. Symptoms would typically last an hour, although on several occasions, they would last until aborted by the administration of either diphenhydramine or epinephrine. She had one documented episode of edema of the lips, but no difficulty swallowing. Hydroxyzine (Atarax) afforded minimal improvement in pruritus, but it was too sedating and did little to prevent her outbreaks. She had also tried loratadine (Claritin), ranitidine (Zantac), and oral steroids without any sustained success. Her condition and associated symptoms have prevented her from participating in mandatory physical training and passing the physical readiness test.

Her past medical history is unremarkable and is notable for no previous history of seasonal allergic rhinitis, atopy, or other allergies. Her only medication is loratadine, 10 mg daily, for symptom control. She had no other history of skin rashes. Her examination was equally unremarkable with no cutaneous lesions. She did not exhibit dermatographism. Skin-prick allergy testing was remarkable for 2+ reactions to pecan tree aUergens, and 1 + to molds, with a 3+ reaction to histamine, and a 0 reaction to control. Pulmonary spirometry tests were unremarkable. Intradermal methacholine chloride challenge (0.1 mg of methacholine in 0.1 mL normal saline intradermally) caused the development of small satellite lesions. Provocative exercise treadmill testing yielded a stable blood pressure (systolic range: 120-130 mm Hg; diastolic range: 76-82 mm Hg) and an appropriate increase in pulse (range, 82-128). After 18 minutes of testing, the patient stopped the test due to fatigue and lightheadedness. Her body temperature had increased from 97.2 to 99.4�F and she was sweating. At 21 minutes from the start of the test, she developed an outbreak of small, 2-mm papules (Fig. 1) over her trunk and extremities. By 47 minutes, the number of papules had increased and had begun to coalesce into wheals (Fig. 2), the largest confluent lesion measuring five centimeters. Repeat pulmonary spirometry after the exercise provocation test was essentially unchanged.

The patient was diagnosed with cholinergic urticaria (CU), given cetirizine HCL (Zyrtec), 10 mg twice a day, which provided significant improvement, but incomplete resolution. Montelukast (Singulair), 10 mg once a day, and propanolol HCL (Inderal), 20 mg twice a day, were added. Since she became stable on the regimen, she is able to shower, clean her house, and exercise. Her perspiration has returned to normal. She now participates in command physical training, running 1.5 miles with minimal irritation and no outbreaks.

DISCUSSION

The physical urticarias are a unique subgroup of the chronic urticarias which can occur through a variety of mechanisms, including allergic, idiopathic, cytotoxic, and autoimmune. Physical urticarias have a wide variety of triggers as well, including water, heat, cold, exercise, sunlight, pressure, and vibration.

CU was first described by Duke in 1924, as a subset of the physical urticarias. Thirty percent of patients with physical urticarias have CU. The majority of the cases occur over the age of 20 and the peak incidence between 26 and 28 years of age.1 Symptoms are brought on by an increase in heat, physical exercise, spicy foods, or extreme emotions. Of those with CU, exercise is the most provocative factor, able to cause an outbreak in 89%. Passive warming (sauna or hot bath) can cause symptoms in 80%, while strong emotions can lead to an attack in 60%; finally, spicy food is able to trigger an attack in 29%.2 The condition will usually improve with time and 14% of CU patients can develop spontaneous remission.3 CU can evoke significant disability to those afflicted with the disease. The level of disability, based on Dermatology Life Quality Index, is similar to severe atopic dermatitis and is much greater than psoriasis or acne.4