Author: Dr. Wu Bin/Professor, Dermatology and Venereology Beauty Center, Affiliated Hospital of Southern Hunan University.
★ The etiology is complex and the clinical manifestations are diverse.
The cause of chronic urticaria is extremely complicated, and it is difficult for most patients to find the exact cause. Common reasons are as follows:
1. Genetic defects: Most patients with chronic urticaria have genetic defects. Studies have shown that chronic urticaria is often a polygenic genetic disease, manifested as genetic allergy. Under the action of various external allergic factors, the immune system of the body is dysfunctional. It is worth mentioning that chronic urticaria is immune dysfunction rather than immune hypofunction.
2. External inducing factors: Most chronic urticaria must have inducing factors, including (1). Food-fish, shrimp, crab and eggs are the most common; Secondly, some plant foods such as strawberries, cocoa, tomatoes or garlic are condiments. Some foods can cause urticaria, but some stale foods are decomposed into peptides, and basic peptides are diluted by histamine. Protein foods can be absorbed in the form of peptone or polypeptide before being thoroughly digested, which can cause urticaria. (2) Drugs-Many antipyretics can easily cause allergic reactions in the body, leading to this disease. Commonly used are penicillin, serum preparations, various vaccines, furazolidone, sulfanilamide and so on. There are also some drugs because they are histamine releasing substances such as aspirin, morphine, codeine, quinine and hydralazine. (3) Infection-including viruses, bacteria and parasites. The most common causes of upper respiratory tract infection are virus and Staphylococcus aureus, followed by hepatitis virus. Most chronic infection focuses, such as sinusitis, tonsillitis and chronic otitis media, are closely related to urticaria. (4) Physical factors-physical stimuli such as cold, heat, sunshine, friction and pressure. The latest authoritative experiment confirms that the free alkali of allergic people is much higher than that of non-allergic people! The invasion of free radicals into human immune system is the basis of allergic constitution, and it also directly oxidizes human mast cells and basophils, leading to cell membrane rupture, histamine release and allergic reaction. Therefore, to improve allergic constitution, free radicals must be removed. (5) Animal and plant factors-such as insect bites, nettles stimulating or inhaling animal dander, feathers and pollen. (6) Mental factors, such as mental stress, can cause the release of acetylcholine. (7) Visceral and systemic diseases, such as rheumatic fever, rheumatoid arthritis, systemic lupus erythematosus, malignant tumor, infectious mononucleosis, metabolic disorder, endocrine disorder, etc. Can be the cause of urticaria, especially chronic urticaria.
3. Abnormal immune function: This is the direct cause of chronic urticaria.
Clinical manifestations of chronic urticaria Urticaria is a common disease, which occurs at least once in a person's life 15%-25%. According to the course of disease, it can be divided into acute urticaria and chronic urticaria. The former can be cured in a short time, while the latter is difficult to cure after repeated attacks. The systemic symptoms of chronic urticaria are generally mild, with frequent wheezing, recurrent attacks for months or decades, some recurrent attacks, such as aggravation in the morning or before going to bed, and some irregular. Most patients can't find the specific reason. There are many special manifestations: (1) Dermatology: Also known as artificial urticaria, it is the itching caused by scratching the skin with hands or scratching the skin along the back edge with blunt objects, which soon disappears and may appear alone or accompanied by urticaria. (2) Cold urticaria: There are two kinds, one is autosomal dominant inheritance, which is rare and occurs soon after birth or early years, and it is repeated for life. After contact with cold air, cold water or cold objects, wheal or patchy edema will appear at the exposed or cold objects. In severe cases, hand numbness, lip numbness, chest tightness, palpitation, abdominal pain, diarrhea, syncope and even shock may occur. Sometimes eating cold drinks can cause edema in the mouth and throat, and the passive transfer test can be positive. After the patient's serum is passively transferred to the corresponding skin, the corresponding allergen is injected locally, causing local redness and itching, which is a positive reaction. This test can be used to understand the types of allergic antibodies and find allergens. (Positive indicates antigen-antibody reaction). (3) Cholinergic urticaria: more common in young people. Because of exercise, heat, nervousness, eating hot drinks or alcoholic drinks, the deep body temperature rises, prompting acetylcholine to act on mast cells. Wind masses appear a few minutes after stimulation, often distributed in the upper torso and upper limbs. (4) Solar urticaria: rare, caused by medium-wave and long-wave ultraviolet or visible light, the most sensitive wavelength is 300nm. (5) Stress urticaria: About 1 hour after the skin is compressed, the compressed part is red and swollen, involving dermis and subcutaneous tissue, which is common in the soles of feet and the compressed buttocks after walking. The mechanism is unknown, which may be similar to skin scratch. (6) Vascular edema: it is a kind of localized edema that occurs in subcutaneous tissue or loose mucosa, and can be divided into two types: sexual edema and hereditary edema. The latter is rare. Acquired angioedema is often accompanied by other hereditary allergic diseases, which mainly occur in loose parts such as eyelids, lips, external genitalia, hands and feet. Most of them are single and occasionally happen in more than two places. Damage is sudden local swelling, involving subcutaneous tissue, and the boundary is sometimes unclear.
★ The pathogenesis is not completely clear.
The doctor's misunderstanding of this disease
Most clinicians do not know enough about the harm of chronic urticaria. They believe that chronic urticaria will not cause damage to other systems. Some doctors even think that chronic urticaria cannot be cured. Actually, it is not. Our study found that about 95% of chronic urticaria can be completely cured, and less than 5% of patients are autoimmune urticaria, which needs to be maintained for life like SLE patients! Such doctors ignore that the human body is an organic whole; Problems with the immune system will inevitably cause damage to other systems. In fact, chronic urticaria is small, and numbness is troublesome (1). It is life-threatening: chronic urticaria, if it occurs in the larynx and bronchus of respiratory tract, will lead to recurrent laryngeal edema, laryngeal obstruction, shortness of breath, chest tightness, dyspnea, and even suffocation and death in severe cases; The condition is serious, accompanied by symptoms of anaphylactic shock such as palpitation, irritability, nausea, vomiting and even blood pressure drop, which endangers life safety; (2) Inducing other diseases: If chronic urticaria is accompanied by gastrointestinal symptoms, it will cause nausea, vomiting, diarrhea and abdominal pain, and gastrointestinal dysfunction; Accompanied by ulcerative colitis and Crohn's disease. The main cause of chronic urticaria is immune dysfunction, so it can induce nephritis, autoimmune hyperthyroidism, SLE, and even low immune monitoring function leading to malignant tumors! Women in reproductive period can also lead to immune infertility and abortion! (3) Affect the quality of life: If chronic urticaria is not cured in time, it can be delayed for several months or even years, and itching in the morning or before going to bed will be aggravated, which will affect people's normal life and psychological state. Therefore, chronic urticaria must be thoroughly treated, rather than untreated as some doctors say, which will eventually lead to serious consequences!
★ Patients are eager for successful treatment.
It is suggested that the incidence of chronic urticaria is caused by many factors and it is difficult to treat. Because the key factor of the disease is immune dysfunction, the focus of treatment should be on regulating immune balance rather than improving clinical symptoms. This is a misunderstanding of most clinicians and patients in the treatment of chronic urticaria. The treatment of chronic urticaria takes a long time, and doctors need to cooperate closely with patients, so don't rush for success. You should consult an expert in this field for treatment. Some necessary tests must be done. Don't be afraid to spend money. You should also work closely with the doctor to find out the possible causes. In the process of treating diseases, you should combine treatment with nursing. Keep the following points in mind in daily life: (1). Don't scratch: this action can't stop itching, and it may get itchy more and more. When you scratch locally, it will raise the local temperature and release blood. (2) Don't apply hot compress: Hot compress can make local itching disappear temporarily, but thermal stimulation will dilate blood vessels and release more allergens, which is likely to induce urticaria repeatedly. (3) Diet: Eat more fresh fruits and vegetables rich in vitamins or take vitamins C and B, or B6 in group B. Eat more alkaline foods, such as grapes, green tea, kelp, tomatoes, sesame seeds, cucumbers, carrots, bananas, apples, oranges, radishes, mung beans and nuts. (4) Enjoy life by combining work and rest: pay attention to rest, don't be tired, and exercise moderately. Because the conduction pathways of nervous system, immune system and endocrine system are the same, mental state seriously affects the onset and treatment of diseases, so you should participate in some recreational activities during treatment.
★ How to completely cure chronic urticaria
As mentioned earlier, chronic urticaria has complex etiology, unclear pathogenesis, great difficulty in treatment and long course of treatment. Correct handling needs to be: (1). Looking for the cause, every patient should try to find the cause of the attack and avoid it. Ask the medical history in detail to find out whether there are family diseases, atopic dermatitis, allergic rhinitis, acute and chronic infection history, medication history, occupation, etc. Living habits and environmental changes. Routine blood, urine and stool tests were performed, and skin allergen test, ice test, acetylcholine skin test, serum IgE test and serum complement test were performed when necessary. Individual patients should also do HBV-DNA and thyroid antibodies, malignant tumors and other tests! (2) Avoid inducing factors such as cold urticaria and keep warm. Acetylcholine urticaria reduces exercise, sweating and mood swings, while contact urticaria reduces contact opportunities. (3) Most patients who use antihistamines can achieve satisfactory results after treatment with antihistamines, and a few patients are stubborn. For intractable urticaria, the dosage can be increased or combined with medication. H 1 receptor antagonists have strong antihistamine and anti-inflammatory mediators, and have good therapeutic effects on various types of urticaria. Commonly used H 1 receptor antagonists include diphenhydramine, cyproheptadine, chlorpheniramine, Avastin, cetirizine, mizolastine, loratadine, ebastine (10mg/d), azelastine (4mg/d), desloratadine (5mg/d) and so on. We can choose two different types of H 1 receptor antagonists or combine them with H2 receptor antagonists (cimetidine and ranitidine). Antaile has strong antihistamine, anticholinergic and sedative effects, and also has good antipruritic effect. It is effective for acute and chronic urticaria and cold urticaria. The initial dose for adults is 25mg each time, 3 ~ 4 times/d; And it can be gradually adjusted to 50 ~ 100 mg each time, 3 ~ 4 times/d. doxepin is a tricyclic antidepressant, which is mainly used to treat depression and anxiety. This drug also has strong resistance to H 1 and H2 receptors. It is reported that doxepin, as an antagonist of H 1, is more than 700 times stronger than diphenhydramine and 50 times stronger than antipyrine. As an H2 antagonist, it is 6 times stronger than cimetidine, and the dosage is 25mg each time, three times a day. It is especially effective for chronic urticaria with few side effects. Doxepin is a better choice for urticaria patients whose traditional antihistamines are ineffective. (4) Select drugs that can inhibit degranulation of mast cells and thus reduce histamine release. Ketotifen; The maximum dose per time is 1mg, three times a day. By increasing the concentration of cAMP in the body, the degranulation of mast cells is inhibited, and the release of inflammatory mediators (such as histamine and slow-response substances) is prevented. Its inhibitory effect is stronger and faster than that of sodium cromoglycate, and it can be taken orally. Tranilast) 100 mg, 3 times a day, reducing histamine release by stabilizing mast cell membrane. (5) Glucocorticoid has strong anti-inflammatory and anti-allergic effects. It can stabilize mast cell membrane and lysosomal membrane and inhibit the release of inflammatory mediators and lysosomal enzymes; Can contract blood vessels and reduce exudation. It has good curative effect on urticaria, especially on acute measles, serum urticaria, stress urticaria and autoimmune urticaria. Commonly used drugs and dosage are as follows: prednisone 40 ~ 80 mg/d, taken orally for 3 ~ 4 times; Diprosone 1ml, intramuscular injection, once a month 1 time, changed to oral preparation after the disease was controlled. In case of emergency, hydrocortisone 200 ~ 400 mg, dexamethasone 5 ~ 20 mg or methylprednisolone 40 ~ 120 mg should be given intravenously. (6). Immunosuppressants When patients with chronic urticaria have an autoimmune foundation and their condition is repeated, and the above treatment cannot achieve satisfactory results, immunosuppressants can be used. Cyclosporine has a good effect. Azathioprine, cyclophosphamide, methotrexate and immunoglobulin can all be tried, and tripterygium wilfordii has a certain effect. (7). Nonspecific antiallergic therapy and other therapies 10% calcium gluconate injection 10ml, 1 time /d, intravenous injection; 10% sodium thiosulfate 10ml, 1 time /d, intravenous injection, 6- aminocaproic acid, 2g each time, 3 times a day, orally; 4 ~ 6g/ time plus 5% glucose solution for intravenous drip; Reserpine 0.25mg /d, 3 times /d, and aminophylline 0. 1 ~ 0.2g, 3 times /d; Transfer factor 1u is injected subcutaneously into the medial arm twice a week, * * * 6 ~ 10 times, which has a certain effect on chronic urticaria. (8) Some special cases, such as urticaria caused by infection, should be treated with appropriate anti-infective drugs according to the infection. A. Among antihistamines for the treatment of cold urticaria, cyproheptadine, doxepin, ketotifen, hydroxyzine and mizolastine have better curative effects; Vitamin e 100 ~ 200mg, 3 times /d, cinnarizine 25mg, 3 times /d can be used in combination with H2 receptor antagonist. Azatadine (1mg, three times a day) has a good effect on cold urticaria through antihistamines, anticholinergic drugs and serotonin. You also need (1) to protect yourself from sudden cooling; ② Among antihistamines, cyproheptadine, doxepin and ketotifen were selected; ③ Sensitize by gradually adapting to low temperature environment and cold water. B for solar urticaria, in addition to antihistamines such as hydroxyzine and chlorpheniramine, hydroxychloroquine 100 ~ 200mg/d and thalidomide 25 ~ 50mg/d can also be taken, and HCH- clinazine 30mg/d can be tried, and repeated irradiation with sunlight or artificial light can be started from a small dose. ④ Apply sunscreen; ⑤ Avoid taking photosensitive drugs and food. C. For cholinergic urticaria, firstly, an anticholinergic H 1 receptor antagonist should be taken before going to bed, such as polima 5mg twice a day or10 mg; Anisodamine 10mg is also acceptable, 2 ~ 3 times/d; (2) Reduced glutathione has a certain curative effect, and its mechanism may be that cholinesterase is activated to hydrolyze acetylcholine; (3) strenuous exercise should be properly restricted; (4) desensitization can be achieved by gradually increasing water temperature and exercise to increase tolerance. (5) It is reported that the combined application of telafilatine and polypyridine mesylate (anticholinergic drug) is very effective. (9) Classification and treatment of traditional Chinese medicine The classification and treatment of urticaria in traditional Chinese medicine are quite inconsistent, but they can be roughly classified into the following types: (a) Wind-heat type: equivalent to acute urticaria. The rash is reddish in color and aggravated by wind. It is advisable to dispel wind and clear heat. The prescription includes: Schizonepeta tenuifolia 15, Radix Saposhnikoviae 12, Fructus Arctii 10, Radix Sophorae Flavescentis 30, Periostracum Cicadae 10, Gypsum Fibrosum 10, Rhizoma Anemarrhenae 15, and Caulis Akebiae/kloc-0. (2) Wind-cold type: equivalent to cold urticaria. It is advisable to dispel wind and cold. Formula Mahuang Decoction or Guizhi Decoction: Herba Ephedrae 15, Ramulus Cinnamomi 12, Radix Paeoniae Alba 10, Notopterygii Rhizoma 10, Radix Paeoniae Rubra 10, Radix Angelicae Pubescentis 9, Radix Saposhnikoviae 5, Herba Schizonepetae 9, and Lemna/kloc-0. (3) Damp-heat type of spleen and stomach: equivalent to gastrointestinal urticaria. Chu Shi Ling Wei decoction and Chen Yin decoction prescription: Poria cocos 20, Atractylodes macrocephala 10, Atractylodes macrocephala 15, Magnolia officinalis 10, Gardenia jasminoides Ellis 9, Artemisiae Scopariae 20, Saposhnikovia divaricata 10, Schizonepeta tenuifolia 15 and Linderae 65438. (d) Yin deficiency and excessive fire: more common in chronic urticaria. Rash often occurs in the afternoon or at night, sometimes appearing, sometimes disappearing, coming and going, and lasting for a long time. Fatigue, sallow complexion, dizziness, dry mouth, flushed cheeks, fever in hands and feet, bright red tongue with bright fur and weak pulse. Treatment should nourish blood, nourish yin and reduce fire. Medicinal Siwu Decoction combined with Artemisia annua Turtle Decoction: Radix Angelicae Sinensis, Radix Rehmanniae, Polygoni Multiflori Radix, Radix Scrophulariae, Cortex Lycii, Radix Paeoniae Alba, Artemisia annua, Carapax et Plastrum Testudinis, Carapax Trionycis, Uncaria Uncaria, Cortex Acanthopanacis, Cortex Dictamni Radicis, Cortex Mori, etc. (e) Irregular type: it is more common in women, and urticaria is caused by menstrual disorder. Rash is periodic, related to menstruation, often irregular menstruation, early or late menstruation. Menstrual abdominal pain, cyanosis or blood stasis. Menstrual eruption is more, and the symptoms are aggravated; After clearing the rash, the symptoms disappeared. Thin fur, purple tongue and number of pulse strings. Treatment should regulate chong ren. The prescription is Taohong Siwu Decoction: peach kernel, safflower, salvia miltiorrhiza, angelica, red peony root, Ligusticum chuanxiong, Cyperus rotundus, costustoot, dodder seed, epimedium, Morinda officinalis, Saposhnikovia divaricata, Schizonepeta tenuifolia, licorice and so on. (f) Burn toxic type: acute urticaria or serous urticaria caused by infection or drugs. Sudden onset, extensive rash, huge body, crimson, burning sensation and itching. Accompanied by fever, nausea, upset, thirst, red eyes, short urine and constipation. Red tongue with yellow coating and rapid pulse. Treatment should clear away heat, cool blood and detoxify. Prescription with Qingwen Baidu drink; Rhizoma Coptidis, Scutellariae Radix, Gypsum Fibrosum, Rhizoma Anemarrhenae, Flos Lonicerae, Radix Scrophulariae, Huang Renzhong, Rhizoma Phragmitis, Rhizoma Smilacis Glabrae, Talcum and Kelp. Introduce another prescription for treating urticaria "Xiaoxi Decoction". Prescription: Herba Ephedrae, Cortex Dictamni Radicis, Kochiae Fructus, Radix Sophorae Flavescentis, and Rabdosia rubescens are decocted in water for 2-3 times. It is reported that general patients are cured in about 10 day, and severe patients are cured in about 20 doses without recurrence. Dosage varies according to the patient's personal situation, and is generally suitable for patients over 65,438+02 years old. (2) Ear acupuncture: Acupoints in spleen, lung, subcortical, adrenal and endocrine areas are taken. (3) Water acupuncture: Acupoints such as Zusanli, Quchi, Sanyinjiao and Shu Fei are selected, and drugs such as procaine, glucocorticoid, antihistamine and compound Danshen injection can be selected. 0.5~lml per point, 2 ~ 3 times a week. (8) The following drugs for external use have astringent and antipruritic effects: ① Compound Luganshi lotion is applied to the rash, ② Liuphenol tincture is applied to the rash, and ⑧ Sanhuang lotion is applied to the rash, and ④ Kochia scoparia, Angelica dahurica, Saposhnikovia divaricata, Zanthoxylum bungeanum and speranskia tuberculata are decocted in water and washed.
(10) the unique therapy of the affiliated hospital of southern Hunan university: antihistamine+cell metabolism drug (anti-free radical)+traditional Chinese medicine monomer Fox3Tr cell immunomodulator * * 3 courses, with an effective rate of 100% and a cure rate of 93.3%. (We have studied this method for 8 years) 367 people have been cured, with the longest medical history of 65,438 people.