224 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
- Acute urticaria is defined as new onset symptoms of
less than 6 weeks in duration. If symptoms persist
more than 6 weeks, it is considered chronic urticaria. - In chronic urticaria, 75% have symptoms over 1 year,
50% have symptoms over 5 years, and 20% have
symptoms for decades. Urticaria occurs at any age,
but is most common in children and young adults.
Approximately 50% of patients at presentation have
both urticaria and angioedema, 40% have urticaria
only and 10% have angioedema only (Tharp, 1996).- Most cases are idiopathic but potential triggers are
medications, insect stings, infections, and foods and
food additives. Table 37-4 lists the most common
known triggers.
•Physical stimuli can also cause urticaria. Physical
urticarias are important to consider in athletes because
they are triggered by conditions occurring during
practice and competition. See Table 37-5 for their
evaluation and management (Casale et al, 1988).- Cholinergic urticaria, from elevation in core body
temperature, is precipitated by exercise or use of
hot tubs. Classically, patients develop small, punc-
tate wheals with prominent erythematous flare.
Symptom usually occur within 2 to 30 min of
exposure and last up to 90 min. - Cold urticaria is precipitated by rewarming follow-
ing contact with a cold object. Within 2–5 min, the
exposed area develops swelling and pruritus.
Symptoms generally worsen as the area is warmed
and last up to 2 h. Patients with cold urticaria
should avoid swimming and diving because this
condition carries a risk of anaphylaxis if patients
have a significant drop in core body temperature. - Aquagenic urticaria is caused by contact with
water. For athletes in water sports, this condition
could be confused with cholinergic or cold
urticaria. Unlike cholinergic urticaria, aquagenic
urticaria occurs even when the water temperature is
cool and even when the patient is not exercising in
the water. Unlike cold urticaria, aquagenic urticaria
will not be precipitated by application of a cold
object that is not water-based.
- Cholinergic urticaria, from elevation in core body
TABLE 37-4 Common Triggers for Urticaria
Medications
Antibiotics
Beta-lactams
Sulfa compounds
NSAIDs
Progesterone
Local Anesthetics
Opioid analgesics
Physical Contacts
Latex
Nickel
Plants and plant resins
Fruits/vegetables
Raw fish
Animal saliva
Insect Stings
Foods and food additives
Milk
Egg
Peanut
Nuts
Soy
Wheat
Fish/shellfish
Sulfites
Infections
Coxsackie A and B
Hepatitis A, B, C
HIV
Ebstein-Barr virus
Herpes simplex
Intestinal parasites
Dermatophyte infectionsTABLE 37-5 Physical Urticarias
TYPE PRECIPITANT EVALUATION TREATMENT
Cholinergic urticaria Elevation in core temperature; History and classic “pencil eraser- Premedicate with nonsedating
Exercise, hot tubs, and the like. sized” punctate wheals antihistamine prior to exercise
Cold urticaria Rewarming after contact Place cold object on skin Nonsedating antihistamines as needed;
with cold object for 15 min and look Avoidance of swimming and diving
for urticaria on rewarming sports because of risk of anaphylaxis
Aquagenic urticaria Water contact History; Expose skin to water and Nonsedating antihistamines
look for changes
Solar urticaria UV light exposure Expose small, unprotected patch Limit sun exposure; Protective clothing
of skin to sunlight and sunscreen use
Pressure urticaria/ Direct pressure on skin. Running, Place 15 lb weight on patient for Avoidance of precipitants; Nonsedating
angioedema prolonged sitting, clapping and 20 min—look for skin changes; antihistamines and NSAIDs; Consider
the like. Test for fever and leukocytosis steroid burst/taper if symptoms severe
3–12 h later
Symptomatic Stroking or rubbing skin; Areas Look for linear, pruritic wheal Loose fitting clothing; Treatment usually
Dermatographism where clothing or equipment 2–5 min after rubbing the skin not necessary. Nonsedating
abrades skin antihistamines only for severe
symptoms