- Matthew J Zirwas, MD
Matthew J Zirwas, MD
- Associate Clinical Professor
- The Ohio State University
The term "urticarial dermatitis" describes an intensely pruritic, recalcitrant skin eruption characterized by erythematous papules and plaques that resemble urticaria but last longer than 24 hours and are sometimes accompanied by eczematous lesions . Histologically, urticarial dermatitis is described by most pathologists as a "dermal hypersensitivity reaction," a nonspecific reaction pattern that is seen in a broad range of skin conditions, including drug reactions, scabies, and the prodromal phase of bullous pemphigoid . However, in a subgroup of patients no underlying cause can be determined.
The incidence and prevalence of urticarial dermatitis are unknown. It occurs most frequently in individuals older than 50 years, with a slight female predominance [3,4].
The pathogenesis of urticarial dermatitis is incompletely understood. One hypothesis is that urticarial dermatitis is a lymphocyte mediated (type IV) hypersensitivity reaction. Clinical and histologic similarities have been noted between urticarial dermatitis and eruptions that occur in patients treated with anti-CTLA4 antibodies to break self-tolerance during immunotherapy for cancer . This finding suggests that urticarial dermatitis may represent a waning of the regulatory function of the immune system that allows a reaction to develop against a self-antigen.
The pathologic features of urticarial dermatitis are nonspecific and include a normal stratum corneum, mild epidermal edema with minimal spongiosis, and a superficial to mid-dermal perivascular infiltrate of lymphocytes and eosinophils with occasional neutrophils (picture 1) . A few basal apoptotic keratinocytes are sometimes present. Similar features may be seen in a variety of skin conditions, including drug reactions, arthropod assault, viral infections, and prodromal stage of bullous pemphigoid.
Patients with urticarial dermatitis typically present with an extremely pruritic, persistent eruption of dull red papules coalescing into plaques, associated with areas of urticated erythema, sometimes accompanied by eczematous lesions (picture 2C). In contrast with urticaria, lesions last for more than 24 hours and often for many days or weeks .
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