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28
Jun

A 56-year-old woman with 20 years of chronic hives (urticaria) and 18 years of eczema

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Case Presentation

A 56-year-old female Singaporean was seen in this clinic in December 2009 because of severe night itchy caused by chronic hives (urticaria) and eczema.

The patient had been well until 20 years earlier, when raised red papules suddenly attacked her, she felt intensive itchy and burning sensation on the wheal area, and then it disappeared within one hour. On the next few days, the hives came and went away almost daily and last few hours sometimes and interfered with her sleep, she sought for medication and understood from her doctor that she got urticaria and was introduced antihistamine to relieve itching. Till 18 years ago, she was told she received comorbidity of eczema with chronic urticaria, she need to take medicines daily to control rashes and itchy with a few kinds of combine antihistamine. However the severe itching seriously disrupted her work and sleep and caused her sleepless at night, in December 2008 she started suffering with insomnia. She sought for further medication beyond antihistamine and saw two more TCM clinics and administrated with TCM herbal powder and decoction 6 months dose without clinical responses. She claimed she was diligent on her medication prescription. In August 2009, around four months before we saw her, she went for skin specialist and was prescribed with 6 weeks dosage of prednisone (oral steroid) and topical steroid cream, the subsequent laboratory evaluation revealed mild osteoporosis which may be secondary to glucocorticoid therapy or may be related her menopausal.

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On examination, the patient’s temperature, pulse, respiratory rate and blood pressure are in the normal range, no joint pain complained. She disclosed the pruritus were intermittent throughout the day but was especially worse in the midnight with its consequences of scratching, she had tried out all kinds of antihistamines, no H1 antihistamines or H2 antihistamines worked on her night pruritus currently, she had to wake up at 12am and 4am every morning to comfort her hives, her quality of sleep was seriously damaged. Some small to large blisters accompanied with deep seated vesicles noted on her palm, large blisters may rupture spontaneously, leaving oozing or dried up erosions mixed with blisters (Fig.2-A), this is a kind of vesicular palmoplantar eczema called pompholyx. Erythematous papules shown on her abdominal area (Fig.1-A).

The patient was advised to stop immunosuppressant therapy (topical or systemic steroid) and introduced Tangs derma-zema capsules, 1440 mg three time a day. On the following one month, puffiness and swelling of the eyelids and mouth developed, she felt a sensation of fullness in the area of the swelling, the severity of itchiness was not reduced, she was crying and complained how suffering he had received at subsequent follow up visit. On the 4th month of TANGS medication, she had not received wheals attack on her face and reduced the antihistamine to half tablet every night, at the subsequent 2 months treatment, she totally discarded antihistamine, and the duration of itchiness was declined to 5 to 10 minutes at each hive onset. Her vesicular palmoplantar dermatitis was improved concurrently with reduced pruritus. At the month 9 treatment, the frequency and severity of wheal and flare were significantly reduced, the itchy is not much bothersome for her, but she was unable to sleep well in midnight. After 13 months treatment, patient received full eczema and urticaria clearance (Fig.1-B, Fig.2-B). There was no other therapy apart from TANGS was given to the patient because of the continuing response and improvement. In the recent follow up through the telephone in April 2011, she said she was sleepless, I asked if sleepless was due to itchiness, she said no because she used to sleepless in past 3 years and woke up at 12am and 4am even without pruritus. Currently she is seeking for the cure for insomnia, I wish her sleep well in the near future.

Discussion

Hives (urticaria) when there is a reaction that activates immune cells in the skin, called mast cells. When activated, these mast cells release natural chemicals; one of the important chemical is histamine, which causes itching, redness and swelling of the skin in certain area. In most cases, hives appear suddenly and disappear within several hours. A condition called angioedema develops in up to one-half of people with hives. Angioedema is similar to hives but occurs in the deeper layer of skin, symptoms of angioedema include, puffiness of the face, eyelids, ears, mouth, hands, feet and genitalia, a sensation of fullness in the area of the swelling, swelling that usually affects one side of the body or affects one side more than the other.

Hives can also occur as part of a more serious allergic reaction. You should see A&E (accident and emergency) if you develop hives or angioedema suddenly along with following symptoms:

  1. Trouble breathing
  2. Tightness in the throat
  3. Nausea or vomiting
  4. Cramping abdominal pain
  5. Passing out

The first treatment for hives is to figure out what is triggering the hives and then avoid that trigger. However it is difficult to figure out the trigger as hives usually disappear over hours or days. In most cases of chronic hives the cause is unknown. Researchers suspect that problems in the immune system play a role.

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