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An 18-year-old college student presents with a complaint of a skin condition that “comes and goes” several times a week. He noticed the first episode about a month ago. Each episode is accompanied by varying degrees of itchiness and lasts 1 to 3 hours. The patient is otherwise healthy and is taking no medications, has no history of food allergy, and does not take illicit drugs. Pressure with a pencil eraser resulted in a red, zig-zag appearance.
Dermatographic urticaria, also known as dermatographism, is a common inflammatory condition that is classified under the inducible chronic urticaria category.1 It is defined as an abnormal erythematous whealing reaction of the skin due to pressure or trauma. In literal terms, it...
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Dermatographic urticaria, also known as dermatographism, is a common inflammatory condition that is classified under the inducible chronic urticaria category.1 It is defined as an abnormal erythematous whealing reaction of the skin due to pressure or trauma. In literal terms, it means “to write on the skin.” The response can occur within 5 to 10 minutes of stroking, scratching, or pressure to the skin and lasts anywhere from 15 to 30 minutes.1
Dermatographism generally presents in young adults within the second or third decades of life but can affect those of any age.2 The trunk and extremities are most commonly affected due to location and surface area, with the scalp and genital area reported less frequently.1 The 2 most common types are simple and symptomatic dermatographism. Simple is more common and nonpruritic, in comparison with symptomatic, which is associated with pruritus and is worse in the evening.1,2
Trauma activates mediators released from mast cells resulting in erythema and a dermal response consisting of capillary dilation and fluid transudation.3 Some cases are linked to hypereosinophilic syndrome, Helicobacter pylori infection, bug bites, scabies, and antibiotic use, such as penicillin.1-3
Treatment is primarily centered around avoidance of precipitating factors such as physical stimuli if an underlying cause cannot be identified and corrected. Idiopathic cases can last for several years. Therapeutics that target the histamine pathway (H1 and H2 antihistamines) are used as first-line therapy.4 Cases that are refractory to antihistamine therapy may respond to omalizumab, a humanized monoclonal anti-immunoglobulin E.5 Additional therapies may include phototherapy, physical desensitization, and immunomodulatory agents.4,5
Alexandra Stroia, DO, is a PGY-1 Transitional Year Resident at Geisinger Community Medical Center, in Scranton, Pennsylvania. Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
References
1. Nobles T, Muse ME, Schmieder GJ. Dermatographism. In: StatPearls [Internet]. StatPearls Publishing; February 20, 2023.
2, Komarow HD, Arceo S, Young M, Nelson C, Metcalfe DD. Dissociation between history and challenge in patients with physical urticaria. J Allergy Clin Immunol Pract. 2014;2(6):786-790. doi:10.1016/j.jaip.2014.07.008
3. Kulthanan K, Church MK, Grekowitz EM, et al. Evidence for histamine release in chronic inducible urticaria: a systematic review. Front Immunol. 2022;13:901851. doi:10.3389/fimmu.2022.901851
4. Amin P, Levin L, Holmes SJ, Picard J, Bernstein JA. Investigation of patient-specific characteristics associated with treatment outcomes for chronic urticaria. J Allergy Clin Immunol Pract. 2015;3(3):400-407. doi:10.1016/j.jaip.2014.12.007
5. Jeong SH, Lim DJ, Chang SE, Kim KH, Kim KJ, Park EJ. Omalizumab on chronic spontaneous urticaria and chronic inducible urticaria: a real-world study of efficacy and predictors of treatment outcome. J Korean Med Sci. 2022;37(27):e211. doi:10.3346/jkms.2022.37.e211
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