After angioedema, urticaria does not go away. Depending on the course and manifestations, urticaria is divided into

Urticaria (urticaria) - a disease characterized by a rapid, more or less widespread rash of itchy blisters on the skin. A blister is swelling of a limited area of ​​mainly the papillary layer of skin. One type of urticaria is Quincke's edema(giant urticaria, angioedema), in which the swelling extends to the dermis or subcutaneous layer. This form of urticaria was first described by N. Quincke in 1882.

Urticaria is a common disease - approximately every third person has suffered from urticaria at least once in their life. In the structure of diseases of allergic origin, urticaria ranks second after bronchial asthma, and in some countries (Japan) even first.
Urticaria and angioedema can occur at any age. The disease most often occurs between the ages of 21 and 60. Women are more often affected, which is associated with the characteristics of their neuroendocrine system. According to various authors, burdened allergic heredity is noted in 25-56% of cases.

Classification of Urticaria.

Etiopathogenetic classification of urticaria

I. Allergic

• Food
• Medicinal and chemical substances
• Household
• Epidermal
• Pollen
• Whey
• Insect
• Infectious

II. Physical

• Mechanical
• Cold
• Thermal
• Radial
  a) light
  b) for x-ray irradiation
• Cholinergic

III. Endogenous

• Enzymopathic:
  a) deficiency or insufficient activity of the C1 inhibitor;
  b) deficit digestive enzymes
• Dishormonal
• Idiopathic

IV. Pseudo-allergic.

Examples of possible diagnoses:
1) acute (pseudo) allergic drug-induced urticaria;
2) chronic recurrent allergic urticaria (bacterial);
3) chronic recurrent endogenous urticaria (dishormonal).

Each of the forms of urticaria indicated in the classification has its own mechanism of development. However, their common pathogenetic link is an increase in the permeability of the microvasculature and the development acute edema in the surrounding area. Pathohistologically, in the area of ​​the blister, loosening of collagen fibers, intercellular edema of the epidermis, and the appearance of perivascular mononuclear infiltrates with varying rates of development and severity are noted.

Allergic Urticaria.

Allergic mechanisms of tissue damage take part in the development of this form of urticaria. The most common allergens are medications, food products, and insect allergens.
The leading mechanism for the development of urticaria is the reagin mechanism of damage, not large quantities cases - immunocomplex. The latter can be activated when a number of drugs (for example, penicillin), antitoxic serums, and gamma globulins are introduced into the body.

Physical Urticaria.

Physical urticaria is caused by various physical factors.
Heterogeneous in pathogenesis. Allergic, pseudoallergic and other mechanisms may participate in its development.

Mechanical urticaria develops as a result of mechanical irritation of the skin.
The following types are distinguished:
a) dermographism - the appearance of a linear blister after holding a hard object over the skin. The mechanism of development is probably allergic, since this reaction can be passively transferred to the skin of a healthy recipient by serum or IgE, and in some patients, after intense scratching, an increase in histamine levels is found in the blood;
b) urticaria from pressure on the skin of buckles, ribbons, belts, etc. The mechanical factor plays a role here. Often accompanies dermographism or chronic urticaria;
c) vibrational angioedema, which is a variant of hereditary angioedema.

Cold urticaria is also a heterogeneous group in terms of developmental mechanisms and clinical manifestations.
Highlight:
a) Hereditary family forms, immediate and delayed, each of which is inherited as autosomal dominant trait. The immediate form cannot be transmitted with serum. The delayed form develops 9-18 hours after exposure to cold. It also cannot be conveyed passively. Contact with cold does not cause histamine release and histologically, skin mast cells are not degranulated. Neither immunoglobulins nor complement were found in the area of ​​edema. Thus, the pathogenesis remains unclear;
b) Acquired forms. The reagin mechanism of damage most often plays a role in their development, which proves the possibility of passive transmission to healthy recipients.
An increase in histamine levels was detected in the blood. The reaction to contact with cold develops quite quickly.

Heat urticaria.
The active factor is heat. One of the possible developmental mechanisms is the alternative pathway of complement activation.

Radiation urticaria occurs under the influence of visible and X-ray rays. In the visible spectrum, rays with a certain wavelength are active. This is the basis for the division of light urticaria into subgroups. The mechanisms of development of urticaria are different. The possibility of passive transfer has been described in cases of urticaria caused by rays with wavelengths of 285-320 and 400-500 nm. When exposed to X-rays, they form free radicals, causing damage to cell membranes.

Cholinergic urticaria.
The active factor is obviously overheating of the body, which occurs after a warm bath, shower, physical activity or other influences. The leading role is attributed to the action of the parasympathetic neurotransmitter nervous system- acetylcholine. At the same time, in a number of cases, an increase in the content of histamine in the blood, as well as the possibility of passive transfer, have been established.

Endogenous Urticaria.

This group includes urticaria (and angioedema), in the mechanism of development of which a genetically determined defect of some factors plays a role or the mechanism of which is not yet known.

Enzymopathic urticaria presented two types.

One kind associated with deficiency of the inhibitor of the first complement component. This defect is inherited as a dominant autosomal trait. The mutation frequency of this gene is 1:100,000. The result is the development of congenital angioedema (Quincke's edema).

There are three types of this disease, clinically indistinguishable.
First type- inhibitor deficiency - accounts for about 85% of cases.
With the second type its level is normal, but the inhibitor is inactive.
With the third type the inhibitor level is increased 3-4 times, but it is structurally changed and forms a complex with albumin. Inhibitor deficiency leads to the fact that various damaging effects that activate the Hageman factor lead to the activation of complement along the classical pathway

Another kind enzymopathic urticaria is associated with dysfunction gastrointestinal tract. Urticaria develops against the background of gastroduodenitis and peptic ulcer. Drinking alcohol under these conditions increases the permeability of the intestinal barrier and enhances the absorption of incompletely digested foods. The latter, independently and through the activation of pseudo-allergic mechanisms, lead to the development of urticaria. Due to the fact that this process is chronic, developing urticaria also has a chronic course.

Dishormonal urticaria.
Its development is associated with dysfunction of the endocrine glands. A typical example is urticaria premenstrual syndrome. The relationship between cortisol and histamine plays a role in their influence at the level of microcirculatory vessels. Any shift towards the predominance of histamine action will lead to increased vascular permeability.

Idiopathic urticaria.
This diagnosis is made in cases where the doctor does not know either the cause or the mechanism of development of the disease. Therefore than more complete examination patient, the less often this diagnosis appears. The disease is chronic. Often this form is enzymopathic and associated with dysfunction of the gastrointestinal tract. Sometimes idiopathic urticaria is a symptom of another disease, for example, systemic lupus erythematosus, glomerulonephritis, infective endocarditis, cryoglobulinemia. In these cases, activation of complement by the resulting immune complexes is often detected. During a biopsy, vasculitis with perivascular lymphocytic infiltration is found.

Pseudoallergic forms of urticaria.

Often, urticaria is an expression of a pseudoallergic reaction. Various acting factors can be histamine liberators, complement activators and the kallikrein-kinin system. These factors include medications (antibiotics, x-ray contrast agents and many others), serums, gamma globulins, bacterial polysaccharides, physical, etc.

Clinical picture of Urticaria.

The clinical picture of acute urticaria is characterized by a monomorphic rash, the primary element of which is a blister. The disease begins suddenly with intense itching of the skin of various parts of the body, sometimes the entire surface of the body. Soon, at the sites of itching, hyperemic areas of the rash appear, protruding above the surface. As the swelling increases, the capillaries are compressed and the color of the blister turns pale. With significant exudation, a blister with detachment of the epidermis may form in the center of the edema.

Urticaria can become hemorrhagic due to its release from the vascular bed shaped elements blood. Subsequently, red blood cells, disintegrating in the surrounding tissue, form pigment spots, which should not be confused with urticaria pigmentosa (mastocytosis).
The size of the rash elements varies - from a pinhead to gigantic sizes. Elements can be located separately or, merging, form elements with bizarre outlines and scalloped edges.

Duration of the acute period - from several hours to several days. Hives may recur. If its total duration exceeds 5-6 weeks, then the disease becomes chronic.
An attack of acute urticaria can be accompanied by malaise, headache, and often a rise in temperature to 38-39° C.

Chronic recurrent urticaria characterized by an undulating course, sometimes for a very long time (up to 20-30 years) with various periods of remission. Very often it is accompanied by Quincke's edema. In chronic urticaria, transformation of urticarial elements into papular elements is occasionally observed. This form of urticaria is characterized by particularly painful itching. Patients scratch the skin until it bleeds, causing infection, resulting in the appearance of pustules and other elements. In this case, the rash is not monomorphic.

Quincke's edema.

If the edema spreads deeper and covers the entire dermis and subcutaneous tissue (sometimes spreading to the muscles), then the appearance of a large, pale, dense, non-itchy infiltrate is observed, which, when pressed, does not leave a hole. This giant edema is called Quincke's edema. With widespread rashes of this type, we are talking about giant urticaria.
They can also occur on mucous membranes. Their most common localization is lips, eyelids, scrotum, mucous membranes of the oral cavity (tongue, soft sky, tonsils).

Particularly dangerous is Quincke's edema in larynx area, which occurs in approximately 25% of all cases. When laryngeal edema occurs, first there is hoarseness of the voice, a “barking” cough, then difficulty in breathing increases with shortness of breath of an inspiratory, and then inspiratory-expiratory nature. Breathing becomes noisy and stridorous. The complexion acquires a cyanotic hue, then becomes sharply pale.

Patients are restless and tossing around. When the edema spreads to the mucous membrane of the tracheobronchial tree, bronchial asthma syndrome with characteristic diffuse expiratory wheezing is added to the picture of acute laryngeal edema. In severe cases, in the absence of rational assistance, patients may die due to asphyxia. With mild to moderate severity, laryngeal edema lasts from an hour to a day. After the acute period subsides, hoarseness, sore throat, difficulty breathing remain for some time, and dry and moist rales are heard on auscultation. Quincke's edema in the larynx requires immediate attention intensive care up to tracheostomy.

When edema is localized on the mucous membrane of the gastrointestinal tract, abdominal syndrome. It usually begins with nausea, vomiting first food, then bile. Acute pain occurs, initially local, then spread throughout the abdomen, accompanied by flatulence, enhanced peristalsis intestines. During this period, a positive Shetkin's symptom may be observed. The attack ends with profuse diarrhea.
In stool, microscopic examination reveals significant amount eosinophils, Charcot-Leyden crystals may be present. Abdominal edema is combined with skin manifestations in 30% of cases.

When the pathological process is localized in urogenital tract the picture is developing acute cystitis, then urinary retention occurs. Swelling of the genital organs is accompanied by a corresponding clinical picture.

When localizing processes on the face the process may involve the serous meninges with the appearance meningeal symptoms, such as stiff neck, severe headache, vomiting, and sometimes convulsions. Rarely, Meniere's syndrome develops as a result of swelling of the labyrinthine systems. Clinically, it manifests itself as dizziness, nausea, and vomiting.

Described rare cases, when with localization of Quincke's edema on the chest the heart was involved in the process with clinical manifestations in the form of attacks paroxysmal tachycardia, extrasystoles (Ado A.D., 1976). Thus, the clinical picture and severity of edema are determined by the localization of the pathological process and the degree of its intensity.

Pathogenesis.

According to the pathogenesis, angioedema can be allergic and hereditary. Clinical manifestations and their course are different.
Although hereditary angioedema is transmitted as an autosomal dominant trait, the absence of a family history does not exclude the diagnosis of this disease. Crucial has a combination of characteristic clinical picture and data laboratory examination. The clinical picture of hereditary angioedema is characterized by prolonged formation of very dense edema, with laryngeal edema and abdominal syndrome often occurring in the absence of indications of skin itching and urticaria, and there is no effect from antihistamines.

Differential diagnosis.

The diagnosis of urticaria is generally not difficult in typical cases of the disease. However, there are many other diseases that masquerade as urticaria.

Due to sudden swelling hemorrhages may be accompanied by a bluish, red and pink small urticarial rash, which is localized mainly on the extensor surfaces, around the joints.

Urticaria, accompanied by hemorrhages, must be differentiated from urticaria pigmentosa - mastocytosis, the morphological expression of which is the accumulation of mast cells in the dermis.

Chronic recurrent urticaria, which has elements of a papular rash, can be mistaken for in which the main elements are pale, skin-colored papules that leave behind age spots.

Accompanied by severe symptoms general, symmetrical location of a non-pruritic, often painful rash, its localization on the back of the hands and feet (which is rarely observed with urticaria), damage to the mucous membranes in the form of a vesicular rash. In severe cases, the skin rash may be vesiculobullous in nature, accompanied by severe general condition sick

Multiple insect bites or stings, causing local toxic reactions due to a histamine-like effect toxic substances saliva or poisons, can simulate acute urticaria.

sometimes accompanied by severe and persistently recurrent urticaria, which cannot be treated with antihistamines and corticosteroids. After deworming, urticaria is completely relieved in the absence of antiallergic therapy.

Macular form of the rash during the secondary period syphilis may sometimes be urticarial in nature. In the differential diagnosis with urticaria, it is necessary to take into account the absence of itching in a syphilitic rash, often its symmetrical location and confirmation of syphilis by positive specific serological reactions.

Often, symptomatic urticaria develops with latent diabetes, diseases of the blood, liver, chronic renal failure. Sometimes urticaria is the first symptom of an unrecognized neoplasm, collagenosis, and can appear in the prodromal stage of infectious hepatitis.

Specific allergological examination of patients with urticaria and angioedema, in addition to collecting allergy history, includes skin testing. In case of food and drug allergies, provocative tests with by oral administration product or medication unless there is a severe reaction to the product.

TREATMENT OF HURTICS AND ANVINCE'S EDEMA.

At Acute urticaria and Quincke's edema carry out the same treatment as for other acute allergic reactions, with an impact on different pathogenetic links of the process.

• Antihistamines prescribed orally (for food and drug allergies) after preliminary cleansing of the gastrointestinal tract or parenterally in a dose of 1-2 ml.
• With giant urticaria, hypotension may be observed due to the release of plasma from the vascular bed; in this regard, injections of 0.1% are prescribed Adrenaline solution in a dose of 0.1 to 0.5 ml subcutaneously, depending on the severity of the condition.
• For swelling of the larynx, in addition to adrenaline and antihistamines, 60 mg should be administered Prednisolone intramuscularly or intravenously in a stream of 20 ml 40% Glucose solution.
• In addition, hot foot baths, inhalation Euspirana,Izadrina, intramuscular injection of 2 ml of 1% solution Furosemide (Lasix).
• If there is swelling of the larynx, the patient needs urgent hospitalization in the ENT department, where, if necessary, he will undergo Tracheostomy.

Chronic recurrent urticaria A requires persistent and long-term treatment. Treatment of chronic urticaria is divided into nonspecific and specific.

Nonspecific therapy.

• Assign Antihistamines, which need to be changed every 2 weeks.
• Can be recommended Sodium thiosulfate, magnesium thiosulfate.
• Externally, to reduce itching, wipe with table vinegar or use ointments with 2-5% anesthesin.
• Histaglobulin(foreign histaglobin) is prescribed according to a regimen taking into account the tolerability of the drug. Regular scheme for chronic recurrent urticaria: 0.5-0.7-1 - 1.5-2-2-2-2-2-2 ml. Injections are made subcutaneously 2 times a week. If the treatment is effective, the course can be repeated after 6 months - 1 year.
• Treatment pure Histamine start with a threshold dilution determined by allergometric titration. Treatment with histamine is best carried out in an allergy department.
• In especially severe cases of the disease, in the absence of effect from other therapy, it is necessary to use Corticosteroid drugs according to an individual scheme.
• If in clinical picture chronic recurrent urticaria has a hemorrhagic component (vasculitis), should be prescribed Indomethacin and others NSAIDs.
• Effective in some cases Splenin(1 g daily, 14-20 injections in total).

Specific therapy.

• Held allergen elimination and/or Specific Hyposensitizing therapy. Elimination means the exclusion of a suspected (or identified) food product from food or medicine.
• Sanitation of foci of focal infection is necessary for urticaria of bacterial or fungal origin. Complete remission of urticaria is possible after tonsillectomy, radical sanitation of the oral cavity, maxillary sinuses, etc. Specific hyposensitization with the identified allergen is carried out according to the generally accepted treatment regimen for allergic diseases.

During treatment Hereditary angioedema antihistamines and corticosteroids are ineffective.

• To relieve acute edema, urgent replacement therapy is needed to compensate for the deficiency of the C1 inhibitor. The patient is given fresh or fresh frozen blood plasma. Lyophilized C1-inactivator, which is administered in a dose of 3000 to 6000 units (1-2 ampoules) depending on the severity of the case and body weight.
• Some effect is noted when administered Adrenaline and Ephedrine.
  Patients require urgent hospitalization: for swelling of the larynx - to the ENT department, for abdominal syndrome- to the surgical
• To prevent relapses introduction of this disease is recommended Epsilonaminocaproic acid(plasminogen inhibitor): IV 5 g from 20 ml to 40% Glucose solution or orally 7-10 g daily for a month
• Sometimes it is recommended to introduce Inhibitor Kallikreina-Trasylol at a dose of 30,000 units in 300 ml of isotonic solution sodium chloride drip for 3 hours.
• Treatment courses also help Methyltestosterone(activation of O inhibitor synthesis in the liver).
• Antihistamines are not always effective in the treatment of dermographic urticaria. Recommended use Sedatives and restorative drugs. Good results have been noted from the use of ultrasound. Treatment is carried out according to the Bogdanovich method: total segmental treatment with paravertebral ultrasound along the entire spine on both sides. Treatment is carried out 3 times a week, up to 12 sessions in total. After a month's break, the course of treatment is repeated.
• Effective reflexology.

Treatment requires a special approach Cholinergic urticaria. Since acetylcholine plays a leading role in the pathogenesis of this type of urticaria, antihistamines and corticosteroids are ineffective.

• The effect is provided by injections of 0.1% Atropine solution, Belladonna extract 0.015 g 3 times a day. Good results Give treatment with dosed physical activity.

Treatment requires great persistence Cold urticaria .

• In some cases, there is an effect from the course Histaglobulin (or histamine), sanitation of foci of focal infection.
• More efficient Autoserotherapy, which begins with the introduction of serum (under strictly sterile conditions) in dilutions of 10 ~ 2 or 10-1 according to the scheme 0.1-0.2-0.3-0.4-0.5-0.6-0.7 - "),8-0.9 ml. The serum was obtained from blood taken from the patient immediately after strong cooling of the hand under running cold water, which caused the appearance of hives.

During treatment Endogenous enzymopathic urticaria, associated with dysfunction of the gastrointestinal tract, used according to indications

• Gastric juice, plantain juice, festal type enzymes, Dysbacteriosis is treated. For patients with chronic recurrent urticaria with concomitant diseases of the gastrointestinal tract, sanatorium-resort treatment is recommended at resorts such as Essentuki, Gruskavets, Marshansk, etc.

Treatment of chronic recurrent urticaria is also complicated by the fact that combinations of etiological different forms hives.

Forecast.

The prognosis for urticaria of allergic origin is favorable in most cases. Quincke's edema localized in the larynx is life-threatening. The prognosis is unfavorable for hereditary angioedema. Families are described where several generations suffered from this disease and died before the age of 40 from asphyxia due to angioedema of the larynx.
Prevention of chronic recurrent urticaria and Quincke's edema is the timely sanitization of foci of focal infection, deworming, and treatment of chronic diseases of the gastrointestinal tract.

An acute allergic reaction in children can manifest itself as skin rash bright red rash or angioedema. Both states can be interconnected and follow each other. Therefore, emergency care for urticaria and Quincke's edema in children should be provided without delay.

Any allergic reaction in a child can develop slowly or rapidly, so home medicine cabinet must always be present antihistamines in the form of tablets and ampoules for intramuscular injection. Most often, the time-tested Suprastin is used in children. The simplest skin test can protect you from a drug allergic reaction. Scratch inner surface forearm and place 2 drops of the medicinal substance that you are going to give to the child onto the scratch. If no redness appears after 15 minutes, you can use the drug without fear.

However, an allergic reaction can be to food, air, animals, flowers and many other allergens. Therefore, we will talk about how first aid is provided.

Severe allergic skin reaction in a child

Urticaria is a severe allergic reaction in a child, characterized by the rapid appearance of urticarial rashes on the skin and, less often, on the mucous membranes.

This allergic skin reaction in a child occurs most often on medicines; food products; nutritional supplements; infectious agents; concomitant somatic diseases (digestive organs, glands internal secretion etc.); inhaled substances (plant pollen, house dust, fungal spores, detergents and other surfactants, acids, alkalis); psychological and emotional stress; insect bites and various physical influences on the skin (high and low temperatures, friction, long-term pressure, vibration, insolation), as well as other reasons. In some cases, the immediate cause may not be clear. Traditionally, according to the course of the disease, urticaria is divided into acute (duration less than 6 weeks) and chronic (duration more than 6 weeks).

Symptoms of an allergic reaction in children

Symptoms of an allergic reaction in children appear, such as a feeling of heat, itchy skin, skin changes, like after a nettle burn. Elements of urticaria - blisters and papules - can be of various shapes and sizes, often merging and acquiring gigantic sizes. The color of the urticaria elements ranges from pale pink to red. The rashes are localized on any part of the body, most often on the stomach, back, chest, and thighs. Symptoms of swelling of the pharynx, larynx, bronchial walls, esophagus, stomach and other organs may appear on the mucous membranes. In such cases, in addition to typical urticaria, difficulty breathing (laryngo- and bronchospasm), vomiting, abdominal pain, and diarrhea occur. General symptoms are possible: increased body temperature, agitation, arthralgia, collapse.

A child has an allergic reaction: what to do?

The first thing to do in case of an allergic reaction in a child, if an allergen is identified, it is necessary to stop its entry into the body. Administer antihistamines intramuscularly or intravenously: (2.5% solution of pipolfen at the rate of 0.1-0.15 ml/year of life or 2% solution of suprastin - 0.1-0.15 ml/year of life) or orally (Claritin , Kestin, Zyrtec, Telfast). For widespread urticaria with fever, administer a 3% solution of prednisolone - 1-2 mg/kg intramuscularly or intravenously. Give activated carbon at a dose of 1 g/(kg-day). If there are signs of intoxication, prescribe infusion therapy (isotonic sodium chloride solution, hydroxyethyl starch derivatives).

Exclude from the diet foods with high allergenic activity (so-called obligate allergens).

These include:

• Cow's milk,
• fish,
• Eggs,
• Citrus,
• Nuts,
• Honey,
• Mushrooms,
• Chicken meat,
• Strawberries,
• Malina,
• Strawberries,
• Pineapples,
• melon,
• persimmon,
• Grenades,
• black currant,
• Blackberries,
• Chocolate,
• Coffee,
• Cocoa,
• Mustard,
• Tomatoes,
• Carrot,
• beets,
• Celery,
• Grape.

All of these products can cause both IgE-mediated allergic reactions and spontaneous degranulation of mast cells directly. Hospitalization to the somatic department (SD) is indicated in the absence of effect from the therapy, and also provided that the patients were administered prednisolone at the prehospital stage due to the severity of the condition.

How does angioedema manifest in children: emergency care

Quincke's edema - an allergic reaction immediate type, manifested by angioedema with its spread to the skin, subcutaneous tissue, and mucous membranes.

The causes of Quincke's edema are the same as for urticaria.

Clinical picture or how angioedema manifests itself in children: characterized by the sudden appearance of a limited increase in volume in places with loose subcutaneous tissue, most often in the area of ​​the lips, ears, neck, hands, and feet. The swelling can reach a significant size and deform the affected area. The immediate danger of this reaction is frequent development mechanical asphyxia due to swelling of the upper respiratory tract. When laryngeal edema occurs in a child, barking cough, hoarseness, difficulty in inhaling and possibly exhaling due to bronchospasm. In cases of swelling of the tongue, speech becomes difficult, chewing and swallowing processes are disrupted.

Emergency care for angioedema in children begins with immediately stopping the intake of the allergen. Administer antihistamines intramuscularly or intravenously: 2% suprastin solution - 0.1 ml/year of life or 2.5% solution of pipolfen - 0.1 ml/year of life, or clemastine intramuscularly 0.025 mg/(kg-day); 3% solution of prednisolone intramuscularly or intravenously at a dose of 1-2 mg/kg. For emergency relief of edema, diuretics (hydrochlorothiazide + triamterene, diacarb furosemide) can be used. With increasing swelling of the larynx positive effect provides inhalation therapy using (32-adrenergic mimetics (salbutamol), glucocorticosteroids for inhalation through a nebulizer (budesonide). When signs appear respiratory failure(DN) III degree(diffuse cyanosis, severe tachycardia, arrhythmic, shallow breathing, drop in blood pressure), the child is immediately transferred to the emergency room, measures are taken to restore airway patency (tracheal intubation, mechanical ventilation), in severe cases a tracheostomy is applied. If there are signs of intoxication, prescribe infusion therapy(isotonic sodium chloride solution, hydroxyethyl starch derivatives). Hospitalized in SO.

Quincke's edema and urticaria develop for one reason - damage to the skin and adjacent tissues is provoked by one or another allergen. In the first case, the pathological process covers the subcutaneous tissue and causes severe swelling of the tissue. With urticaria, an allergic reaction manifests itself in upper layers skin - blisters form, painful, itchy and take a long time to heal. Urticaria in chronic form, periodically aggravating, becomes a source discomfort for months and years. In the case of Quincke's edema, minutes count - with swelling of the neck, the patient's life hangs in the balance due to possible asphyxia(choking).

Why does Quincke's edema occur?

Urticaria with angioedema appears after allergens enter the body, causing degranulation of mast cells. Provoke allergic reaction Hives can also be caused by physical factors (cold, heat, solar radiation, insect bites), as well as chemical compounds in small doses dissolved in ordinary water. Much more often, hives are triggered by food allergens and ingredients of popular medications.

Quincke's edema is essentially a complication of urticaria, when the pathological process covers not only the upper layers of the skin, but penetrates deeper and involves the mucous membranes, subcutaneous fatty tissue and muscles. Less commonly, Quincke's edema develops as an independent disease.

In more than 25% of patients with urticaria, the leading role in its development and angioedema is played by a hereditary factor; in another third, such phenomena are acquired during life.

For any clinical variety urticaria significantly increases the permeability of small blood vessels. The surrounding tissues quickly swell, and under the influence of excess histamine, large blisters form on the surface of the skin. The allergic reaction gradually affects the deep layers of the skin and subcutaneous tissue - this is how angioedema begins.

Clinical manifestations

For allergens entering the body skin covering reacts very quickly. Bright pink blisters appear within just one hour. If urticaria occurs in an acute form, after three to five hours the skin is completely cleared of rashes.

Urticaria often occurs against the background of:

• liver pathologies;
• diseases of the digestive system;
• infectious diseases;
• helminthic infestation.

Urticaria with Quincke's edema, in addition to dermatological ones, is accompanied by other symptoms. Along with a rash on the skin, there is an increase in body temperature to 38 degrees, headaches, sleep disturbances, and a feeling of powerlessness.

In chronic form, urticaria may last for long months with periodic exacerbations. In addition to the visible manifestations of urticaria, nausea and vomiting are periodically disturbing, increased nervousness.

If swelling occurs:

• in the throat area - the victim’s voice becomes hoarse, breathing becomes wheezing, speech is impaired;
• in the pleura - occurs sharp pain in area chest, severe shortness of breath;
• in the brain - one of the most dangerous variations, leads to circulatory problems and seizures;
• in the digestive system - bothers strong pain in the stomach, nausea and subsequent vomiting;
• in the bladder area, its functionality is impaired, the process of urination is extremely painful.

Diagnostics

Diagnosis of angioedema on the face and neck special problems does not cause due to the severe severity of symptoms. With extensive damage, this area swells very much. The larynx and digestive tract are most often affected not by acquired, but by Quincke's edema with hereditary factor.

It is more difficult to diagnose angioedema if the process occurs in the internal organs. Performed differential diagnosis Quincke's edema with other edema that occurs against the background of:

• pathologies thyroid gland, in particular, with hypothyroidism;
• disorders of the liver and kidneys;
• inflammation of connective tissue (dermatomyositis);
• blood diseases;
• oncological pathology.

Angioedema of allergic origin requires anamnesis and identification of hereditary predisposition to its occurrence.

What to do if Quincke's edema is detected

Urticaria with Quincke's edema can be fatal. If characteristic symptoms occur, you should immediately call ambulance.

Before doctors arrive, the victim should be provided with a constant flow of air - open the window. It is necessary to relieve the pressure on the body of the wardrobe items - unbutton the collar of the shirt, the belt on the trousers. It is best to take a relaxed position while sitting.

It is necessary to immediately limit contact with the allergen if it is known what caused the swelling, and drink a large amount of liquid (preferably alkaline - Borjomi, Narzan) to eliminate it from the body. With Quincke's edema in the throat area, especially with rapid development, urgent hospitalization is needed.

It is advisable to have antihistamines (for example, Diazolin, Fenkarol) and sorbents (activated carbon, Enterosgel) in your home medicine cabinet.

Quincke's edema in many cases develops in a matter of minutes. To alleviate the condition, take an antihistamine, which will ease the symptoms and help the victim until the ambulance team arrives.

If we are talking about a food allergen, sorbents are taken, but in no case are the stomach washed out because of the risk of choking on vomit.

Treatment of swelling and urticaria

The basic principle of treating urticaria and angioedema is eliminating the provoking factor. After cupping acute condition, when the patient’s life is no longer in danger, he is transferred, depending on the type of edema and current condition, to one or another department. If the patient's condition is not dangerous, this may be in the therapeutic or allergy department.

Urgent Care

Quincke's edema with urticaria is a direct threat to life. During hospitalization, measures are taken promptly to relieve tissue swelling. If the swelling is localized in the throat area, tracheal intubation is performed - to ensure respiratory function, an endotracheal tube is inserted into the organ.

Under no circumstances should you attempt to make a tracheal incision on a patient yourself! These manipulations are performed only by doctors.

In a complicated situation, when there is no time and conditions for tracheostomy, in order to ensure breathing, a dissection of the larynx (more precisely, the conical ligament between the cricoid and thyroid cartilages) is performed - conicotomy. In case of Quincke's edema in the digestive organs, the patient is referred to surgery department.

Elimination

Depending on the allergen, food provocateurs are completely excluded from the menu. Risky products include:

• chocolate;
• citrus;
• seafood (crustaceans);
• tomatoes;
• strawberry;
• peanut;
• pork;
• sauerkraut;
• fermented cheese;
• red wine.

This does not mean that you should give up all these products forever. After identifying the allergen, only it is excluded from the menu.

Drug therapy

Treatment of urticaria with Quincke's edema is carried out using:

• antihistamines (Claritin, Suprastin);
• diuretics (Lasix);
• glucocorticosteroids (Prednisolone, Dexasone);
• protease inhibitors (Contrical).

Sorbents are selected individually for the patient to cleanse the body of the allergen. Additionally, calcium and vitamin C supplements are prescribed to strengthen the nervous system, and multivitamin complexes that enhance the tone of blood vessels.

For angioedema with a dominant hereditary factor, a drug is individually selected to replenish the volume of the missing C1 inhibitor.

In the case of pseudoallergic Quincke's edema, the patient is prescribed an intravenous drip of isotonic sodium chloride solution (for example, Contrikal).

Preventive measures and diet

The main rule for the prevention of angioedema is to avoid contact with allergens by any means. If this household dust- monitor the cleanliness of the premises, regularly carry out wet cleaning. If there is plant pollen, avoid places where it blooms.

When it comes to food allergens, you should check the foods you eat for the presence of food additives. It's about about:

• flavor enhancers;
• dyes;
• preservatives.

Patients who have urticaria and angioedema due to poor heredity should be careful when undergoing any surgical interventions. When visiting the dentist, be sure to report the problem.

Before any procedure involving surgical intervention, the attending physician will prescribe a special course aimed at preventing the possible occurrence of Quincke's edema. For this purpose, patients with urticaria are prescribed tranexamic acid or androgens. Additional drugs are administered immediately before the operation itself.

Hives- a heterogeneous disease, which is characterized by the appearance of urticarial rashes on the skin.

Quincke's edema ( giant urticaria) - a hereditary or acquired disease characterized by swelling of the skin and subcutaneous tissue. At angioedema swelling of the mucous membranes may develop.

Both diseases occur at any age, but more often between 20 and 40 years. In almost half of the cases, urticaria is combined with Quincke's edema.

Most often, the formation of blisters is associated with the release of histamine. Most often, degranulation of mast cells is caused by fixation of IgE on their membrane during atopy.

However, histaminoliberation is also possible when immune complexes, as well as complement fragments, are fixed on the membrane of mast cells, as happens with immune complex urticaria. Degranulation of mast cells can be associated with various cytokines, interleukins 1 and 8, neuropeptides (substance P, somatostatin), histamine-releasing proteins secreted by neutrophil leukocytes at the site of inflammation, lymphokines.

Some medicinal substances(codeine, coumarin anticoagulants, penicillin, various dextrans, morphine, polymyxin, indomethacin, sulfonamides, B vitamins, contrast agents), fixing directly on the membrane of mast cells, can cause the release of histamine without involving immune mechanisms in the process. A genetically determined mast cell defect is also possible.

In such cases, various physical effects on the skin (pressure, high and low temperatures, etc.) lead to their degranulation.

In addition to histamine, acetylcholine, released during nervous stimulation, can provoke the formation of blisters. Therefore, a cholinergic type of urticaria is isolated.

Thus, it is pathogenetically justified to distinguish allergic, autoimmune, non-allergic and idiopathic urticaria.

Clinical manifestations.

For hives Characterized by the appearance of itchy blistering rashes of various sizes and shapes. The rashes are most often localized on the skin of the trunk and extremities (including on the palms and soles), less often on the face. Blisters can be either single or multiple.

Often there is a merging of the eruptive elements in places of greatest friction (shoulders, hips, buttocks, lumbar region). At allergic urticaria the appearance of rashes is often accompanied by a rise in temperature, a decrease in blood pressure, general weakness. Individual blisters last no more than 24 hours. However, as some elements resolve, new ones often appear.

Quincke's edema can develop both acutely and gradually. The formation of dense painless swelling of the subcutaneous fat is characteristic. Typical localization is the place where loose subcutaneous tissue is located: face (especially lips), oral cavity (soft palate, tongue). The color of the rash is often unchanged, less often pink. Itching, unlike urticaria, is not typical. In a quarter of cases it is affected respiratory system(larynx, trachea, bronchi). In such cases, hoarseness and cough appear, and there is a high risk of asphyxia. Swelling of the walls of the esophagus, stomach, and intestines is possible.

Let's look at the forms of urticaria and Quincke's edema.

Acute urticaria and Quincke's edema last no more than 6 weeks. They are more often observed in young people and are associated with the formation of a type I allergic reaction (IgE-dependent). The greatest etiological significance are medications, food products, and insect bites. Such patients often have a history of other allergic diseases (atopic bronchial asthma, allergic rhinitis and etc.).

Chronic urticaria lasts more than 6 weeks. The diagnosis of this type of urticaria is usually made on the basis of a history of the disease and a characteristic clinical picture: itching, the presence of blisters, their sudden appearance and resolution without the development of any secondary rash elements are noted.

Chronic recurrent urticaria can be widespread and localized. For example, only the palms and soles may be involved in the process. According to the nature of the course, chronic urticaria is divided into recurrent (periods of exacerbations followed by periods of remission) and persistent (blisters appear constantly).

Combinations of chronic urticaria with angioedema and urticaria from pressure are often recorded. In more than half of the cases, it is not possible to determine the cause of the development of chronic urticaria. As a rule, chronic urticaria develops against the background of chronic foci of infection, diseases of the gastrointestinal tract, and helminth infections.

This type of urticaria can occur in leukemia, lymphogranulomatosis, non-Hodgkin lymphoma as a nonspecific hemoderma, and act as a paraneoplastic condition. Cases of a combination of chronic urticaria with autoimmune thyroiditis and idiopathic thrombocytopenic purpura have been described.

For physical urticaria The appearance of blisters on the skin as a result of exposure to various physical factors is typical. Highlight mechanical, cold, thermal, aquagenic, cholinergic, solar hives and urticaria from vibration. Chronic diseases of the gastrointestinal tract and foci of focal infection can act as a provoking factor for physical urticaria.

Mechanical urticaria occurs in response to mild mechanical irritation of the skin. The mechanism of blistering is associated not only with nonspecific degranulation of mast cells, but also with the release of acetylcholine. At the same time, mechanical urticaria occurs quite often in patients with chronic recurrent urticaria. Mechanical urticaria is diagnosed in persons with acute and chronic infectious diseases (tuberculosis, hepatitis, etc.), helminthic infestation, and hypovitaminosis. A special feature is the absence of itching. Antihistamines are usually ineffective.

Cold urticaria accompanied by the appearance of blisters in the cold (most often when swimming in cold water, less often - in frosty, windy weather, when drinking cold water). The development of this urticaria is associated with the formation of cryoglobulins and (or) cold hemolysins, which cause degranulation of mast cells and basophils.

The disease may be hereditary or associated with other diseases (hepatitis, bacterial endocarditis, tuberculosis, syphilis, respiratory viral infections, diffuse diseases connective tissue, tumors internal organs and etc.). The diagnosis is established on the basis of a characteristic anamnesis, as well as the results of a number of tests. The simplest test is to apply an ice cube to the patient’s forearm for a period of 30 seconds to 5 minutes. In this case, blisters appear when the skin warms up.

Cholinergic urticaria accounts for 5% of all cases of urticaria. The provoking factors for the development of the disease are warming ( heat ambient air, taking a hot bath, hot shower, physical activity), emotional excitement, eating spicy and hot food.

Psychogenic urticaria observed in anxiety and stressful situations. The mechanism of its development is similar to the mechanism of development of cholinergic urticaria, which is why many authors identify them. However, when exposed to a psychogenic factor, there is a release of adrenaline and norepinephrine, which, in turn, changes the sensitivity of receptors to acetylcholine, resulting in a vascular reaction.

Development solar urticaria associated with degranulation of mast cells against the background of photosensitivity. Blisters appear on exposed areas of the skin during the first sun exposure in spring. By mid-to-late summer, manifestations of the disease usually disappear. The diagnosis is established on the basis of anamnestic data and the results of a test with ultraviolet rays. As a rule, the development of solar urticaria is associated with liver pathology.

Extremely rare vibration urticaria, in which blisters form when working with vibrating tools, riding a motorcycle, etc. The disease can be inherited in an autosomal dominant manner.

At contact urticaria blisters appear at the site of direct skin contact with an allergen (typical for patients with atopic background) or irritant. U healthy people contact urticaria can be caused by the bites of mosquitoes, bedbugs, flies, mosquitoes, bees, wasps, ants, touch of jellyfish, silkworm caterpillars, contact with turpentine, primrose, etc. A blister appears at the site of contact with the irritant. In some patients, a local reaction may be accompanied by widespread urticarial rashes, Quincke's edema, an asthmatic attack, and even an anaphylactic reaction.

Hereditary urticaria, or hereditary angioedema are inherited in an autosomal dominant manner. The disease often begins in childhood and is associated with a deficiency in the blood of neuraminoglycoprotein, which is a C1 inhibitor. As a result, the synthesis of C3 and C5a complement fragments, which directly cause degranulation of mast cells, is enhanced.

Systemic steroids and antihistamines are ineffective for this form of urticaria. An estrogen-dependent form of hereditary angioedema can develop during pregnancy, when taking estrogen drugs (contraception, hormone replacement therapy).

Treatment of urticaria

Treatment of urticaria includes elimination measures and pharmacotherapy.

At acute urticaria An allergen can only be identified through a detailed study of the patient’s medical history, as well as through vitral tests. To speed up the elimination of the allergen, diuretics are prescribed in combination with drinking plenty of fluids or administration of intravenous drip solutions, enterosorbents. Blockers are prescribed H1 receptors. In severe cases, the administration of systemic glucocorticosteroids is indicated.

In case of Quincke's edema at the prehospital stage, the patient is administered intravenously 2 ml 2.5 % prednisolone solution and intramuscular 2 ml of tavegil. With the development of laryngeal edema, along with the above drugs, 0.5-10 ml of 1% is administered subcutaneously adrenaline solution.

The following shows the transition to oral antihistamines with a prolonged effect (second generation drugs). In case of hereditary angioedema, an infusion of fresh frozen plasma containing C1 inhibitor. Less effective infusion e-aminocaproic acid. As prophylactic agents androgen drugs are used.

At chronic recurrent urticaria A detailed examination of the patient is recommended in order to exclude the source of endogenous sensitization, treatment of the identified pathology, and adherence to diet. Medications prescribed antihistamines of the latter generations long courses (at least several months). If there is no effect, it is possible to prescribe systemic steroids, cyclosporine A, antileukotriene drugs, performing plasmapheresis.

At contact urticaria it is necessary to exclude skin contact with factors that cause an urticarial reaction. External treatment indicated: apply topical steroids and antihistamines (for example, demitendene gel).

At cholinergic urticaria shown belladonna preparations, as an emergency aid - administration of atropine(subcutaneous - 1 ml of 0.1% solution).

At cold urticaria exclude swimming and washing in cold water. Apply antihistamines, in some cases - hemosorption, plasmapheresis. Sometimes “desensitization” techniques to low temperatures are effective: the patient is recommended to first immerse his hand in water at a temperature of 15 ° C for 5 minutes, increasing the exposure time daily. As the process subsides and adaptation to the cold, the area of ​​contact with cold water increases.

At heat urticaria happens occasionally effective technique“desensitization” to heat, similar to the technique used for cold urticaria.

Solar urticaria requires appointment photoprotectors, detailed examination of the condition of the liver. It is recommended to take medications in early spring nicotinic acid, antimalarials, H2 receptor blockers.

Patients with psychogenic urticaria psychotherapeutic and psychopharmacological correction of their emotional status is prescribed. Antihistamines are also indicated, especially the first generation, which give a sedative effect.

Occurs at least once in a lifetime in 15-25% of the world's population and usually before the age of 40 years. Most often children under 3 years of age are affected, a little less often - children of preschool and early age. school age. The rash of urticaria resembles a nettle burn, hence the name of the disease. Primary element The rash is a blister, which is a local swelling of the papillary dermis. Such a rash is called urticarial (from lat. urtica – nettle) and is accompanied by significant itching, leading to deterioration of well-being and sleep disturbance. In half of the patients, urticaria occurs in isolation, in approximately 40% the disease is combined with angioedema (Quincke's edema), and isolated angioedema occurs only in 10-15% of patients and is a deeper swelling of the skin and subcutaneous tissue, which develops on the mucous membranes of the oral cavity and larynx can lead to asphyxia, which threatens the life of the child.

Urticaria can be acute and last for several days and weeks (no more than 6 weeks between the appearance of the first and disappearance of the last elements of the rash) or chronic, lasting months and years. Acute forms of the disease are more common in children, and chronic forms are observed in children aged 20 to 40 years.

Causes of acute urticaria and Quincke's edema in children, in most cases, it can be clearly established. These may be the following factors:
- food products (milk, eggs, fish, nuts, legumes, citrus fruits, chocolate, strawberries, raspberries and others), and the younger the child, the more often food allergens are the cause of the disease;
- medications (antibiotics from the groups of penicillins, cephalosporins, salicylates, non-steroidal anti-inflammatory drugs, blood products, X-ray contrast agents);
- insect bites (wasps, bees, spiders, fleas), jellyfish;
- infections (usually hepatitis viruses, Epstein-Barr, streptococci, helminths);
- physical factors (heat, cold, insolation, physical activity, pressure);
- direct contact of the allergen with the skin (animal hair, dyes, perfumes, latex, household chemicals).

Causes of chronic urticaria can be identified in 20-30% of children, and more often they are physical factors, infections, helminthic infestations, food additives, inhaled allergens and medications.

Mechanisms of development of urticaria and angioedema are divided into two main groups - allergic and non-allergic. In both cases, the basis is the release of biologically active substances from the granules of mast cells, the most studied of which is histamine, itchy, edema and hyperemia. In children, degranulation most often results from immediate-type allergic reactions (IgE-dependent), in which allergens interact with antibodies on mast cell membranes. When exposed to non-immune factors, an increase in histamine concentration occurs due to its direct release from cells upon consumption certain products, medications. In addition, non-immune mechanisms include the effects of physical factors, causing development cold, thermal, contact, solar, vibration urticaria.

For clinical picture urticaria is characterized by the appearance of round or oval blisters ranging in size from a few millimeters to 10-20 cm; they can merge with each other, forming polycyclic figures. Elements of the rash rise above the surface of the skin, have a bright pink color, sometimes paler in the center; can appear in any part of the body, including scalp head, palms and feet, and are accompanied by itching varying degrees expressiveness. The rash turns pale when pressed. It is typical for children acute course urticaria with profuse rash, accompanied by significant swelling and hyperemia.
Children often experience general symptoms: increased body temperature up to 39 degrees Celsius, decreased appetite, pain in the abdomen, joints, and stool disorders. An important feature of urticaria is the complete resolution of blisters without the formation of secondary elements (from several minutes to several hours, but not more than a day).

Special types of urticaria include aquagenic urticaria, which occurs immediately after contact with water of any temperature, characterized by a rash of small blisters surrounded by erythematous spots, and accompanied by severe itching.
In older children, more often in adolescence, the so-called cholinergic urticaria– the appearance of a large number of pale pink blisters with a diameter of 1-5 mm, surrounded by hyperemia. They form after physical activity, stress, sweating, hot shower, and are accompanied by systemic manifestations: hot flashes, weakness, rapid heartbeat, shortness of breath, abdominal pain.

In children angioedema happens less often. It is characterized by the sudden onset of swelling of the skin and subcutaneous tissue, leading to deformation of the affected area. Quincke's edema is localized in areas of skin with scanty connective tissue prone to accumulation tissue fluid– on eyelids, lips, ears, hands, feet, genitals, mucous membranes of the gastrointestinal tract. Itching with Quincke's edema is less pronounced; burning and a feeling of fullness are more common. Resolution occurs more slowly - within 24-72 hours.
With angioedema, the process may involve the mucous membranes of the oral cavity, tongue, pharynx, and larynx with the development of obstruction of the upper respiratory tract, which threatens the life of the child. First, hoarseness of the voice and a barking cough occur, then difficulty breathing appears and increases, inspiratory shortness of breath (difficulty in inhaling) develops, then exhalation becomes difficult, cyanosis of the facial skin increases, giving way to severe pallor. In severe cases, the risk of asphyxia is high. When edema forms on the mucous membranes of the stomach and intestines, the child experiences abdominal pain, vomiting, and bowel movements.

Diagnostics urticaria and angioedema is based on the characteristic clinical picture of the disease. Laboratory and instrumental examinations are prescribed to identify causative factor. Use skin testing with food allergens, specific diagnostic provocative tests. They also search for diseases that contribute to the development of urticaria - helminthic infestations, pathologies of the endocrine and digestive systems.

Treatment of urticaria and angioedema carried out in three main directions: eliminating contact with the provoking factor, prescribing drug therapy and creating a hypoallergenic environment to prevent relapses of the disease.

Of the medications, taking into account the mechanisms of disease development, the most effective are antihistamines in age dosages. For common forms of urticaria and Quincke's edema, parenteral administration is preferable, and then switching to tablet forms for a month or more. For chronic urticaria, treatment is prescribed for 3-6 months, and sometimes up to a year. If antihistamines are ineffective (increasing edema, generalization of the lesion), glucocorticosteroid hormones are used (intravenously).
For food allergies, sorbents are additionally prescribed, for cholinergic urticaria - anticholinergic drugs, for cold - membrane stabilizers, for solar - cyclosporine A. In some cases, plasmapheresis sessions are effective.

At severe form acute urticaria, ineffectiveness outpatient treatment, angioedema of the larynx with a risk of asphyxia, swelling of the tongue, intestines and life-threatening complications, it is necessary to hospitalize the child in a hospital.
If your baby develops swelling of the larynx, some measures must be taken before the ambulance arrives. First of all, you should not give in to panic and calm the child, as anxiety will increase swelling and quickly lead to asphyxia. Next, you should stop contact with the allergen (if an insect bites, remove the sting, if you have a food allergy, rinse your stomach, if you have a drug allergy, stop administering the drug), ensure maximum oxygen flow, remove all constricting objects from your neck and waist, and put some drops in your nose. vasoconstrictor drops. You can independently give your child sorbents and antihistamines in age-appropriate dosages before the doctor arrives.

Prevention of recurrence of urticaria and angioedema
In the most common form of the disease in children - allergic - contact with provoking factors should be avoided if possible. However, often exact reason cannot be detected or contact cannot be avoided. In this case, it is necessary to limit the influence on the child of all factors that can cause an allergic reaction. First of all, you must comply hypoallergenic diet, exclude all foods that can cause the release of histamine or contain it in large quantities. These include chocolate, citrus fruits, seafood, strawberries, eggs, preservatives, cheeses, smoked meats, nuts, tomatoes and others.
Also, you should not allow your child to come into contact with contact (animal hair, household chemicals, dyes, dust, latex) and inhalation (pollen, aerosols) allergens; you should wear loose clothing made from natural soft fabrics, avoid insect bites, and take medications, due to which previously observed the appearance of urticaria.

An important condition for effective elimination of allergies is the treatment of foci chronic infection, diseases of the gastrointestinal tract, including dysbacteriosis, the fight against helminthiases, high-quality therapy for colds and other infectious diseases. Moreover, it is necessary to take general measures to strengthen the baby’s immunity.
In case of urticaria associated with exposure to physical factors, exclude their influence on the child - do not wear tight clothes, do not visit baths, do not drink too cold or hot drinks, do not be exposed to excessive physical activity; avoid direct contact sun rays, use sunscreen with high level UV protection.