Education · Weiterbildung Dermatol Psychosom 2004;5:203–205 Dr. med. Ulrike Raap Department of Dermatology and Allergology Hannover Medical School Ricklingerstr. 5, D-30449 Hannover Tel. +49 511 9246-0, Fax -234 E-mail mail@ulrike-raap.de © 2004 S. Karger GmbH, Freiburg Accessible online at: www.karger.com/dps Fax +49 761 4 52 07 14 E-mail Information@Karger.de www.karger.com Dermatology Psychosomatics Dermatologie Psychosomatik Urticaria U. Raap a U. Gieler b G. Schmid-Ott c a Department of Dermatology and Allergology, Hannover Medical School, b Department of Psychosomatic Medicine, Psychodermatology, University Giessen, c Department of Psychosomatic Medicine, Hannover Medical School, Germany Definition Urticaria (ICD 10: L50.8 – possibly F54) is divided into sever- al subtypes (e.g. acute, chronic, physical, and autoimmune ur- ticaria) and represents one of the most frequent skin diseases. The traditional definition of chronic urticaria is the occurrence of daily or almost daily hives for more than 6 weeks, in con- trast to acute urticaria which disappears within less than 6 weeks. Physical urticarias, such as pressure and cold ur- ticaria, or urticaria factitia also frequently occur concurrently with chronic urticaria. In addition, urticaria is associated in about 40% with angioedema. In general, hives persist less than 24 h, whereas in urticaria vasculitis, which in former times was included in urticaria subtypes due to historical rea- sons, hives persist more than 24 h. The trigger factors for urticaria are manifold. In more than 80% of cases urticaria is triggered by an inflammatory focus, a subclinical infection, or autoimmune actions. Additionally, non-specific pharmacological or toxin-mediated release of in- flammatory mediators of basophils and mast cells can trigger urticaria. Psychodermatologically, chronic urticaria is seen as a multifactorial dermatologic disorder which can be substantial- ly influenced by psychological factors [Schneider and Gieler, 2001]. Various studies report an association between stress, anxiety, or depressive symptoms and chronic urticaria [Sheehan-Dare et al., 1990; Brahler et al., 1994], however, not assuming a causality as reviewed recently [Buffet, 2003]. In daily practice, however, stress is an important trigger factor for urticaria. Ur- ticaria symptoms affect everyday life, limiting and impairing physical and emotional functioning, and act as an indirect bur- den on life satisfaction underlining the major impact on quali- ty of life [Baiardini et al., 2003]. With regard to the subtype of urticaria the impact on quality of life is different, as physical urticaria such as delayed pressure urticaria was shown to have a higher impact with decreased quality of life than other types [O’Donnell et al., 1997]. Dermatological Diagnostics The clinical assessment of urticaria includes taking the pa- tient’s history as well as physical examination. Urticaria is di- vided into the acute (symptoms less than 6 weeks) and the chronic type (symptoms more than 6 weeks), which is identifi- able by exact acquisition of data on urticaria symptoms. For the detection of specific trigger factors, such as pressure, cold contact, or autoimmune interactions, specific tests, e.g. pres- sure test, cold arm bath, cold-cylinder test, and/or autologous serum skin test, are recommended [Raap et al., 2004]. As more than 80% of chronic urticarias are triggered by chronic infections or subclinical foci specific laboratory tests are help- ful: e.g. CRP (c-reactive protein), differential hemogram, serology for streptococcus, staphylococcus, and yersinia, care- ful testing for helicobacter pylori infection, and autologous serum skin test [Wedi et al., 2004]. In acute urticaria however, no specific dermatological investigations are recommended, as acute urticaria generally disappears within less than 6 weeks. As urticaria is often triggered by non-specific pharma- cological inflammatory mediators avoidance of drugs such as acetylsalicylic acid is recommended, as they can elicit urticaria as well as aggravate pre-existing chronic urticaria [Wedi et al., 2000]. Moreover, avoidance or elimination of the eliciting stimulus (e.g. cold contact in cold urticaria) is recommended in urticaria management. Psychosomatic Diagnostics There are only few studies dealing with quality of life in ur- ticaria. However, recently the dermatology life quality index (DLQI) was found to be valid, reliable, and a clinically useful outcome measure for assessing quality of life in patients with chronic urticaria [Lennox and Leahy, 2004]. In a multicenter study performed in 1996 by Hein et al. 100 patients with chronic urticaria were examined with a stan-