Will dermatographia go away
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Continuing Education Activity
Dermatographism, also known as dermographism urticaria, or urticaria factitia, is an urticarial eruption upon pressure or trauma to the skin. The literal meaning is "to write on the skin." Downward pressure on the skin produces a linear wheal in the shape of the applied external force. Dermatographism is the most common type of inducible/physical urticaria, occurring in approximately 2% to 5% of the population. A small subset of those with dermatographism becomes symptomatic with pruritus along with the erythematous wheals. This activity reviews the evaluation and management of dermatographism and the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.
Objectives:
Review the differential diagnosis for dermatographism.
Describe the presentation of dermatographism.
Summarize the treatment options for dermatographism.
Outline the evaluation and management of dermatographism and interprofessional team members' role in collaborating to provide well-coordinated care and enhance patient outcomes.
Introduction
Dermatographism, also known as Dermographism urticaria, or urticaria factitia, is an urticarial eruption upon pressure or trauma to the skin. Urticarial skin reactions present as erythematous wheals in the dermis and can have innumerable causes.Dermatographism is the most common type of inducible/physical urticaria, occurring in approximately 2% to 5% of the population. Downward pressure on the skin produces linear erythematous wheals in the dermis in the shape of the external force applied, earning the name dermatographism, which literally means "writing on the skin." A small subset of people with dermatographism becomes symptomatic with pruritus, stinging, prickling sensations that can be bothersome for the patient.[1]
Etiology
The exact cause of dermatographism is unknown. However, the release of histamine from mast cells is thought to play a role.[2]Dermatographism has been seen in people with diabetes, hyperthyroid, hypothyroid, menopause, pregnancy, or medication-related.
Epidemiology
Dermatographism is the most common type of urticaria, frequently presenting in young adults with the peak incidence in the second and third decades. There has not been shown a relationship between race and dermatographism. One study of pediatric patients showed a female predominance.[3]One report cited a case of familial dermatographism.[4]
Hypereosinophilic syndrome is associated with atopic children and increases dermatographism; these are associated with atopic children and an increased number of eosinophils in the blood. One-third of patients that experience traumatic life events, along with psychological co-morbidities, experience dermatographism.[5] Furthermore, stressful events like pregnancy (commonly in the second trimester) and the onset of menopause have seen a higher incidence of the condition. Behcet disease, a condition marked by oral and genital ulcers, is another disease where dermatographism is a common integumentary finding.
Symptomatic dermatographism is thought to be generallyidiopathic, but various explanations have been considered. The higher consensus revolves around Helicobacter pylori, antibiotics such as penicillin, bites, or scabies as the more common presentations to suggest this correlation. Lastly, congenital symptomatic dermatographism is the presenting sign in systemic mastocytosis.[6]
Pathophysiology
No concluding mechanism explains why dermatographism occurs. Mechanical trauma activates vasoactive mediators released from mast cells secondary to antigen interaction to the bound IgE. This is thought to cause an exaggerated biological response known as the "triple response of Lewis." Initially, the capillaries become dilated, producing a superficial erythematous phase. Next, an axon-reflex flare and communication to sensory nerve fibers cause an expansion of erythema, secondary to arteriolar dilation. Lastly, the linear wheal is formed through fluid transudation. This entire response takes, on average, up to 5 minutes after an external stimulus stroking of the skin. The wheal can persist anywhere from 15 to 30 minutes, unlike the normal triple response of Lewis that subsides in under 10 minutes. Mediators such as histamine, leukotrienes, bradykinin, heparin, kallikrein, and peptides such as substance P are all considered to play a role in this process.
Histopathology
The histopathology of dermatographism demonstratesdermal edema with few perivascular mononuclear cells similar to acute urticaria histology.
History and Physical
Dermatographism lesions appear following mechanical trauma to the skin, most consistently stroking of the skin. Awheal forms and develops in approximately 5 to 10 minutes. The wheal will persist for about 15 to 30 minutes. The deeper the edema into the dermis, the larger the wheal will appear. In symptomatic dermatographism, pruritus accompanies the wheal. The pruritus worsens at night (thought to be related to the pressure of the bedding and sheets contacting the skin) and friction to the area from external stimuli, heat, stress, emotion,and exercise.
Dermatographism most commonly involves the trunk and extremities, and other body surfaces. The least common areas reported are the scalp and genital area; however, symptomatic dermatographism has been correlatedin the literaturewith dyspareunia and vulvodynia.[7]
There are several rare subtypes of dermatographism:
Red dermatographism (small punctate wheals, predominantly on the trunk)
Follicular dermatographism (isolated urticarial papules)
Cholinergic dermatographism (similar to cholinergic urticarialarge erythematous line marked by punctate wheals)
Delayed dermatographism (tender urticarial lesion reappears 3 to 8 hours after the initial injury that persist up to 48 hours)
Cold-precipitated
Exercise-induced
Familial
Treatment / Management
Prevention and avoidance of precipitating factors such as physical stimuli and decreasing stressors are important factors in controlling dermatographism. Most patients are asymptomatic, and therapy should be restricted to symptomatic patients. Choice therapy includes treatment with H1 antihistamines such as cetirizine or loratadine. H2 antihistamines can be combined for more complete therapy if H1 blockers are insufficient to control the pruritus. Hydroxyzine, a sedating antihistamine,is avalidoption andcan be taken before sleep.
Omalizumab is under consideration in research trials focusing on treating dermatographism with 72% efficacy on 150 mg and 58% efficacy on 300 mg. Notably, patients' Dermatology Life Quality Index (DLQI) scale improved by at least 4 points, showing a statistically significant clinical difference.[8]
Light therapy has shown someefficacy in treating dermatographism, yet most patients relapse within 2 to 3 months of completing therapy.
Adjunctive treatment with over-the-counter vitamin C 1000 mg daily is thought to help degrade histamine and increase removal, diminishing the triple response of Lewis.[9]
Differential Diagnosis
If dermatographism is the leading differential, false dermatographism must be ruled out, a condition that presents clinically similar to dermatographism but has a different underlying mechanism. False dermographism has several different forms, including white, black, and yellow. White dermatographismis secondary to allergic contact dermatitis and is prevalent in atopic individuals. Black dermatographism occurs after contact with metallic objects. Yellow dermatographism is due to bile deposits in the skin.
Another condition that presents similarly to symptomatic dermatographism is latex allergy. This commonly is seen on the hands and genital region and will often be related to a history of physically contacting latex in gloves, rubber bands, balloons, toys, or contraceptive use.[10]Mastocytosis, a disorder caused by an increase in the number of mast cells, can also present with pruritic red-brown pigmented lesions. Mastocytosis can be cutaneous or systemic, depending on what area is infiltrated with mast cells. One sign of mastocytosis is called the "Darier sign," which is swelling, pruritus, and erythema in response to pressure applied to the skin.Systemic mastocytosis is more common in adults, and symptoms are based primarily on the organ affected, such as the liver, spleen, bone marrow, or small intestine. Urticaria pigmentosa is the most common cutaneous mastocytosis in children, is rare and benign.[11]
Prognosis
Dermatographism is a benign condition. In a minority of cases, pruritus can accompany the condition. Compared to the other chronic urticarias, symptomatic dermatographism displays the most expedited clearance of the condition after 5 years (36%) and 10 years (51%).[12]
Complications
Dermatographism has no direct complications. However, if the patient uses sedating antihistamines for treatment, they may need to exercise caution before engaging in certain activities such as driving or operating machinery.
Deterrence and Patient Education
Dermatographism can be unsettling in its laborious course without resolve. However, the condition is benign, and patients must beaware of this. The treatment involved, antihistamines, can result in drowsiness; therefore, it is best to advise the patient not to take the medicationbefore operating a vehicle.
Enhancing Healthcare Team Outcomes
Dermatographism is a benign yet startling lesion to most patients and their parents. Thus, it is imperative to educate the patient and their parents properly on the risk factors associated with the onset of dermatographism to avoid such stressors.To properly educate, it is ideal to target the audience in a team-based approach.
Evaluation by theprimary care physician
Consult the dermatologist when the diagnosis is in question
Encouragereduction of external stimuli, effective management, and treatment options.
Illustration of forearm displaying dermatographism on skin. Contributed by Chelsea Rowe
References
- 1.
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 Nov-Dec;2(6):786-90.[
PMC free article: PMC4254441] [
PubMed: 25439372]
- 2.
Azkur D, Civelek E, Toyran M, Msrlolu ED, Erkoolu M, Kaya A, Vezir E, Gini T, Akan A, Kocaba CN. Clinical and etiologic evaluation of the children with chronic urticaria.
Allergy Asthma Proc. 2016 Nov;37(6):450-457.[
PubMed: 27931300]
- 3.
Martorell A, Sanz J, Ortiz M, Julve N, Cerd JC, Ferriols E, Alvarez V. Prevalence of dermographism in children.
J Investig Allergol Clin Immunol. 2000 May-Jun;10(3):166-9.[
PubMed: 10923592]
- 4.
Jedele KB, Michels VV. Familial dermographism.
Am J Med Genet. 1991 May 01;39(2):201-3.[
PubMed: 2063925]
- 5.
Takapan O, Harmanyeri Y. Evaluation of patients with symptomatic dermographism.
J Eur Acad Dermatol Venereol. 2006 Jan;20(1):58-62.[
PubMed: 16405609]
- 6.
Grimm V, Mempel M, Ring J, Abeck D. Congenital symptomatic dermographism as the first symptom of mastocytosis.
Br J Dermatol. 2000 Nov;143(5):1109.[
PubMed: 11069538]
- 7.
Lambiris A, Greaves MW. Dyspareunia and vulvodynia: unrecognised manifestations of symptomatic dermographism.
Lancet. 1997 Jan 04;349(9044):28.[
PubMed: 8988122]
- 8.
Maurer M, Schtz A, Weller K, Schoepke N, Peveling-Oberhag A, Staubach P, Mller S, Jakob T, Metz M. Omalizumab is effective in symptomatic dermographism-results of a randomized placebo-controlled trial.
J Allergy Clin Immunol. 2017 Sep;140(3):870-873.e5.[
PubMed: 28389391]
- 9.
Johnston CS, Martin LJ, Cai X. Antihistamine effect of supplemental ascorbic acid and neutrophil chemotaxis.
J Am Coll Nutr. 1992 Apr;11(2):172-6.[
PubMed: 1578094]
- 10.
Golberg O, Johnston GA, Wilkinson M. Symptomatic dermographism mimicking latex allergy.
Dermatitis. 2014 Mar-Apr;25(2):101-3.[
PubMed: 24603512]
- 11.
Le M, Miedzybrodzki B, Olynych T, Chapdelaine H, Ben-Shoshan M. Natural history and treatment of cutaneous and systemic mastocytosis.
Postgrad Med. 2017 Nov;129(8):896-901.[
PubMed: 28770635]
- 12.
van der Valk PG, Moret G, Kiemeney LA. The natural history of chronic urticaria and angioedema in patients visiting a tertiary referral centre.
Br J Dermatol. 2002 Jan;146(1):110-3.[
PubMed: 11841375]
Disclosure: Timothy Nobles declares no relevant financial relationships with ineligible companies.
Disclosure: Mikel Muse declares no relevant financial relationships with ineligible companies.
Disclosure: George Schmieder declares no relevant financial relationships with ineligible companies.
What Is Dermatographia (Skin Writing)?
Key takeaways:
Dermatographia also called skin writing is a condition where people develop raised red lines when pressure is applied to their skin.
Some people develop severe itching from dermatographia that can interfere with their daily lives.
Taking medications, like antihistamines, and avoiding triggers can help people manage their symptoms.
Have you ever scratched your arm or leg and looked down a few minutes later to find a raised red mark where you scratched? If youve experienced this phenomenon, you may have dermatographia.
People with dermatographia develop raised marks or even hives (welts) when pressure like firm touch or scratching is applied to their skin.
Dermatographia is also called:
Dermographism
Urticaria factiti
Dermographic urticaria
Skin writing
For some people, dermatographia doesnt bother them too much. Some people even turn it into an art form. But other people who experience dermatographia suffer from intense itching and even have trouble wearing certain types of clothing.
If you think you have dermatographia, heres everything you need to know about what causes it, how its diagnosed, and how you can treat it.
What causes dermatographia?
Dermatographism is a kind of allergic reaction. When someone with this condition applies pressure to their skin, their mast cells release a chemical called histamine along with other inflammatory substances.
These substances cause skin redness and swelling better known as hives. But unlike other allergic reactions, these hives dont only look like oval welts. They take the shape of any pressure applied to your skin.
The hives appear within 5 to 7 minutes and fade over 15 to 30 minutes. They may be itchy and usually form on your arms, legs, or torso.
Researchers arent sure why certain peoples bodies release histamine in response to skin pressure, while others dont.
Some older studies show that people develop dermatographism because of triggers like:
Excessively dry skin
Exercise
Strong emotions or stress
Cold weather
Hot water
Infections caused by viruses, bacteria, or fungi
Certain medications, like penicillin
Whos most at risk of dermatographia?
About 5% of people experience dermatographia at some point in their lives. Its more common in younger people, especially children.
People with certain medical conditions are more likely to develop dermatographism, including those with:
People who are pregnant or going through menopause are also more likely to experience dermatographia. And the condition can also run in families.
How is dermatographia diagnosed?
A healthcare provider can diagnose dermatographia by talking to you about your symptoms and doing a provocation test.
During a provocation test, your healthcare provider will stroke the skin on your forearm or back with the blunt end of a pencil or with a special instrument for dermatographia testing. After that, youll wait about 10 minutes to see if raised marks show up along the path of the object. If they do, its very likely that you experience dermatographia.
Make sure you dont take any antihistamines for several days before your provocation test, because they can affect how your body responds to the test.
How do you treat dermatographia?
Some people prefer not to treat their dermatographia, because their symptoms are mild. But about 40% of people have severe itching that interferes with their daily lives. This itching can keep them from sleeping, working, wearing certain fabrics, and even going out in certain types of weather.
Luckily, theres many treatments to help manage or even stop the itching and welts.
Medications and therapies
Medications like antihistamines can treat dermatographia. These include:
Some of these are available over the counter. But its important to talk to your healthcare provider before using them. Thats because some people need much higher doses in order for the medications to work. Others need to start medications called H2 blockers along with antihistamines.
In older studies, UV light therapy lessened symptoms in some people. There is also promising evidence that the monoclonal antibody, omalizumab, can help people with more severe symptoms.
Trigger avoidance
One of the best ways to treat dermatographia is to avoid triggers. With certain changes in your daily life, you may be able to improve your symptoms naturally.
For this to work, you need to know what usually triggers your dermatographia. Keep a journal to see if you can pinpoint these triggers. Some common ones include:
Dry skin: Dry skin is a common trigger for many people. To avoid dry skin, youll need to focus on skin hydration. This includes using non-drying soaps, detergents, and other skin care products. You can also use non-irritating emollients to keep your skin hydrated.
Trauma: Avoid causing direct trauma to your skin, like scratching or rubbing. Choose looser fitting clothing, including undergarments, whenever possible.
Temperature: If temperature is one of your triggers, try to avoid time in the heat or cold when possible. If heat specifically triggers your symptoms, try turning down the temperature in your baths and showers.
Fabrics: Certain fabrics can trigger dermatographia, like scratchy wool or synthetic fibers. Fabrics like cotton and linen might be less irritating.
Diet: Some people notice improvements in their symptoms when they eat a healthier diet that is rich in anti-inflammatory foods.
Stress: Mental health plays an important role in managing your triggers. Make sure youre getting enough sleep, exercise, and mental health support.
Is dermatographia serious?
While dermatographia can affect your daily life, its not considered dangerous. And it doesnt cause any health issues.
Another piece of good news: dermatographia often goes away. Studies show that in 33% of people, it resolves within 5 years. In some people, the condition lasts for as little as 10 days.
Johnsson, M., et al. (1987). UVB treatment of factitious urticaria. Photodermatology.
Kirby, J. D., et al. (1971). The incidence and other aspects of factitious wealing (dermographism). The British Journal of Dermatology.
Kontou-Fili, K., et al. (1997). Physical urticaria: Classification and diagnostic guidelines. An EAACI position paper. Allergy.
Kulthanan, K., et al. (2020). Symptomatic dermographism: A systematic review of treatment options. The Journal of Allergy and Clinical Immunology. In Practice.
Lee, E., et al. (2001). Treatment of urticaria. An evidence-based evaluation of antihistamines. American Journal of Clinical Dermatology.
Liccioli, G., et al. (2020). Dermatographism and urticaria in a pediatric population. Pediatric Allergy and Immunology.
Martorell, A., et al. (2000). Prevalence of dermographism in children. Journal of Investigational Allergology & Clinical Immunology.
Matthews, C. N., et al. (1973). Dermographism: Reduction in weal size by chlorpheniramine and hydroxyzine. The British Journal of Dermatology.
Mlynek, A., et al. (2013). A novel, simple, validated and reproducible instrument for assessing provocation threshold levels in patients with symptomatic dermographism. Clinical and Experimental Dermatology.
Nobles, T., et al. (2021). Dermatographism. StatPearls.
Orfan, N. A., et al. (1993). Physical urticarias. Annals of Allergy.
Skintome. (n.d.). Skintome.
Smith, J. A., et al. (1983). Dermographia caused by IgE mediated penicillin allergy. Annals of Allergy.
Takapan, O., et al. (2006). Evaluation of patients with symptomatic dermographism. Journal of the European Academy of Dermatology and Venereology: JEADV.
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