Localized aquagenic urticaria: efficacy of a barrier cream

A localized salt-dependent aquagenic urticaria successfully treated with omalizumab

We present the first case of a localized salt-dependent aquagenic urticaria confirmed by a challenge test. A good therapeutic response was achieved after only the first dose of omalizumab.

A Systematic Review of Aquagenic Urticaria-Subgroups and Treatment Options

BACKGROUND

Aquagenic urticaria (AquaU) is a rare variant of chronic inducible urticaria where wheals occur after skin contact with water. Information on clinical manifestations and treatment outcomes is limited, which makes the management of AquaU challenging.

OBJECTIVE

To systematically review disease features and relevant triggers of AquaU and patients' response to treatment.

METHODS

Related articles were searched by use of the terms "aquagenic urticaria" and "aquagenic angioedema" until June 2021 and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.

RESULTS

A total of 77 patients with AquaU were investigated in 59 studies including 47 case reports and 12 case series. AquaU predominantly presented in women (47 patients, 61%), and the mean age of onset of the disease was 19.6 ± 10.8 years (range: 0-54 years). Wheals commonly occurred in localized areas and regardless of the water temperature. Based on the reviewed evidence, AquaU can be classified as familial AquaU (FAquaU, 18.2%) and acquired AquaU (AAquaU, 81.8%). Although many treatments were used in both subtypes of AquaU, the use of second-generation H₁ antihistamines (2^ndAH₁) was reported most often to achieve marked improvement in both subtypes. The use of topical therapies in AquaU, which most commonly use hydrophobic vehicles, is poorly documented and of controversial efficiency.

CONCLUSIONS

AquaU is proposed to be classified into 2 subtypes, FAquaU and the more common AAquaU. Treatment with a 2^ndAH₁ is recommended as the first-line treatment for both types of AquaU. Further studies are required to fill knowledge gaps.

Aquagenic urticaria: Water, friend, or foe?

There are <100 reported cases of aquagenic urticaria. Although most are sporadic, several diseases have been associated. Diagnosis is based on provocation tests. Second-generation antihistamines are the first-line treatment.

Review of Physical Urticarias and Testing Methods

PURPOSE OF REVIEW

This review aims to update the information available on the prevalence, clinical picture, diagnostic methods, and treatment of urticarias induced by external physical stimuli.

RECENT FINDINGS

Physical urticarias are present in up to 5% of the general population, and in 10 to 50% of patients with chronic urticaria. Recent investigations have provided evidence that the presence of physical urticaria alone or when comorbid with chronic spontaneous urticaria is associated with a worse prognosis and duration. Most frequent subtypes of physical urticaria are dermographism and delayed pressure urticaria. The diagnosis is established through specific provocation tests and the management encompasses avoidance measures, pharmacologic therapy with nonsedating antihistamines, and alternative medications in refractory cases.

Aquagenic urticaria: diagnostic and management challenges

Aquagenic urticaria (AU) is a rare inducible form of physical urticaria, which occurs in response to cutaneous exposure to water, including sweat and tears. Patients present with characteristic 1–3 mm folliculocentric wheals with surrounding 1–3 cm erythematous flares within 20–30 minutes following skin contact with water. In rare cases, there are concomitant systemic symptoms, such as wheezing or shortness of breath. The pathogenesis of AU is poorly understood at this time, and it appears to be mediated in both a histamine-dependent and independent manner. Diagnosis is based on eliciting a thorough clinical history combined with a water challenge test. Some patients may need to undergo further testing to exclude other physical urticarias. Rarely, multiple physical urticarias can be present in one patient, which can complicate diagnosis and treatment. Currently, the first-line therapy for AU is an oral administration of nonsedating, second-generation H₁ antihistamines, but many patients may require further interventions to have adequate symptomatic control. In this review, we discuss the diagnostic and management challenges of AU. We review the key diagnostic features that differentiate AU from other physical urticarias. We additionally describe a therapeutic ladder for the treatment of AU and the rationale supporting these treatments.

The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision

These recommendations for the definition, diagnosis and management of chronic inducible urticaria (CIndU) extend, revise and update our previous consensus report on physical urticarias and cholinergic urticaria (Allergy, 2009). The aim of these recommendations is to improve the diagnosis and management of patients with CIndU. Our recommendations acknowledge the latest changes in our understanding of CIndU, and the available therapeutic options, as well as the development of novel diagnostic tools.

[Aquagenic urticaria. A case report]

A 38-year-old woman presented with recurrent episodes of urticaria after contact with water affecting the upper part of the body. We confirmed the diagnosis of aquagenic urticaria. Aquagenic urticaria is a rare form of contact urticaria with small wheals generally affecting the upper part of the body. It has to be distinguished from aquagenic pruritus. The pathogenetic mechanisms are not known in detail. Treatment with antihistamines, ultraviolet therapy or application of protective hydrophobic barrier creams could be effective.

An adolescent boy with urticaria to water: review of current treatments for aquagenic urticaria

We report the case of an adolescent boy with aquagenic urticaria unresponsive to oral antihistamine therapy. We successfully treated his condition by topical application of a petrolatum-containing cream as a protective coating. To our knowledge, this is the first report showing the use of topical therapy alone to treat aquagenic urticaria in a child. Based on the effectiveness, safety profile, and ease of use, clinicians may wish to consider this regimen as a first-line therapy.

Localized salt-dependent aquagenic urticaria: a subtype of aquagenic urticaria?

Aquagenic urticaria is a rare form of inducible urticaria characterized by wealing at the site of contact of the skin with water, regardless of its temperature, within minutes of exposure. We describe six young women who reported urticarial rashes, triggered mostly by sea bathing, characteristically localized on the inferior facial contours and neck. In four of the six patients, this was the only localization. All six reacted with erythema and wealing to challenge tests with hypertonic saline (3.5% NaCl) applied to the submandibular area and/or neck. Two patients reacted also to tap water or to normal saline, but less intensely. Challenge tests with different hypertonic water solutions, performed in one patient, showed that both salinity and hypertonicity may be pathogenically relevant. Response to antihistamines was poor in three patients. Our experience suggests the existence of a distinct salt-dependent subtype of aquagenic urticaria (SDAU) that affects young women, with a characteristic localization on the inferior facial contours and neck. SDAU is possibly under-recognized and under-reported.

Aquagenic urticaria: a report of two cases

Aquagenic urticaria is a rare form of physical urticaria, in which contact with water evokes wheals. A 19-year-old man and a 4-year-old boy complained of recurrent episodes of urticaria. Urticaria appeared while taking a bath or a shower, in the rain, or in a swimming pool. Well-defined pin head to small pea-sized wheals surrounded by variable sized erythema were provoked by contact with water on the face, neck, and trunk, regardless of its temperature or source. Results from a physical examination and a baseline laboratory evaluation were within normal limits. Treatment of the 19-year-old man with 180 mg fexofenadine daily was successful to prevent the wheals and erythema. Treatment with 5 ml ketotifen syrup bid per day resulted in improvement of symptoms in the 4-year-old boy.

Urticária aquagênica familiar: relato de dois casos e revisão da literatura

Urticária aquagênica é forma rara de urticária física caracterizada por aparecimento de urticas após o contato com água, independente da temperatura. Há poucos casos descritos de urticária aquagênica e, destes, somente cinco da forma familiar. Apresentamos o primeiro relato de urticária aquagênica familiar no Brasil, acometendo mãe e filha. Ambas apresentavam urticas, principalmente após banho de chuveiro, independentemente da temperatura da água. A mãe referia ter o quadro há quatro anos, e a filha, desde o nascimento. Para diagnóstico, foram realizados testes de provocação com água, com aparecimento de lesões em ambas, e testes com dermografômetro, com cubo de gelo envolvido em plástico e de provocação para urticária colinérgica, sem o aparecimento de lesões, excluindo assim outras formas de urticária física.