Stress and Urticaria

Definition

  • Urticaria (hives)
    • localized wheals (a red, swollen mark left on flesh) to widespread recurrent whealing and angioedema
    • 15-20% of world pop get it at least once in their life
    • Superficial or deeper
    • usually pruritic and often pale in the center because of intense edema, before maturing into pink superficial plaques
    • resolve/gone after 2-24hr (unless damage by excoriation)
    • so usually acute
    • Angioedema -more painful than itchy, and generally takes longer time to resolve
    • 2x/wk for 6 weeks = chronic urticaria
  • Mediators
    • histamine
      • mast cells degranulate to release histamine
    • Emotional factors does not exacerbate cold urticaria
  • Adrenergic urticaria
    • stress induced
    • reproduced with injection of epinephrine and norepinephrin and a beta-blocker, propranlol
    • may coexist with cholinergic urticaria

Role of Psychosocial Stress

  • urticaria can be induced by (emotional) stress
    • acute emotional form
      • follows specific events with a clear cause-effect relationship
    • chronic recurrent form
      • psychodynamic basis as a psychosomatic disease
  • Biomarker – Immunological tests (IgE) is <20% of cases
  • Biomarker – Low serum dehydroepiandrosterone sulfate (DHEA-S)
    • lower DHEA S may mean greater psychological distress amplification
    • Also look at DHEA-S/cortisol ratio

Types of Stress

  • emotional or psychological factors
  • stressful or catastrophic major life events
  • traumatic life events such as abuse and/or neglect during childhood and later life
  • urticaria vs quality of life of patient

Personality Variables and Psychodynamic Formulations

  • Some old theories
    • nervous excitement was associated with the onset of urticaria
    • the vascular reactions in the disease are the same as those that occur after actual trauma to the skin
    • at the time the urticarial reaction occurs the patient appears to be hung dead center between the extremes of passivity and aggression, immobilized in his conflict betwixt abject dependence and destructive rage

Psychological Factors

  • some more old theories
    • a feeling of being wronged or injured, usually by someone in a close family relationship – brought on urticaria
  • The skin temperature and response to mechanical stimuli increased and the reactive hyperemia threshold decreased
    • an increased tendency of both arterioles and minute vessels to dilatation

Skipping (or going super brief) these chapters as it seems self explanatory

  1. Stress from Life Events
  2. Traumatic and Catastrophic Life Events
  3. Childhood Abuse and Developmental Trauma
  4. Urticaria as a Conditioned Response
    • you can get urticaria as an allergic response (i.e. food)

Neuroimmunology

  • The skin has it’s own HPA axis
    • local expression of corticotropin releasing hormone (CRH) and receptors receptors (CRH-R)
  • acute stress and CRH stimulate mast cells
    • this increases vascular permeability through CRH-R1 activation
    • Acute stress increasing CRH triggers mast cell-dependent vascular permeability
  • Major depressive disorder (MDD) and post-tramautic stress disorder(PTSD)
    • both associated with elevated CRH
    • CRH mast cell degranulation is important for symptom exacerbation in urticaria

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