Dermographism Urticaria
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The term dermographism (or dermatographism) literally means writing on the skin. Firm stroking of the skin produces an initial red line (capillary dilatation), followed by an axon-reflex flare with broadening erythema (arteriolar dilatation) and the formation of a linear wheal (transudation of fluid/edema); these events are collectively termed the triple response of Lewis.
An exaggerated response to this constitutional whealing tendency is seen in approximately 2-5% of the population and is referred to as dermographism. In a minority of people, it is accompanied by itching (symptomatic dermographism).
See the image below.
Dermographism should be distinguished from other types of urticaria. See the following articles:
The exact mechanism of dermographism remains uncertain. Trauma may release an antigen that interacts with the membrane-bound immunoglobulin E (IgE) of mast cells, which release inflammatory mediators, particularly histamine, into the tissues. This process causes small blood vessels to leak, allowing fluid to accumulate in the skin. Other mediators that may be involved are leukotrienes, heparin, bradykinin, kallikrein, and peptides such as substance P.
Symptomatic dermographism is usually idiopathic, though it may have an immunologic basis in some patients. Passive transfer of the dermographic response with IgE- or immunoglobulin M (IgM)-containing serum has been reported, but no allergen has been identified.
Symptomatic dermographism may be triggered by drugs (eg, penicillin), an insect bite, Helicobacter pylori infection, or an infestation (eg, scabies, Fasciola hepatica). Congenital symptomatic dermographism has been described as the first sign of systemic mastocytosis. [1]
Approximately 75% of patients with hypereosinophilic syndrome, which has multisystem involvement and high mortality, have dermographism. Psychological factors and a history of stressful life events have been implicated as triggering factors in 30% of patients. [2] However, a small prospective study showed no alteration in dermographic reaction after social stress provocation tests. [3]
One case report describes symptomatic dermographism secondary to trauma from a coral reef. [4] Symptomatic dermographism may be a presenting feature of dermatomyositis. [5]
Dermographism is the most common of the physical urticarias and can occur with other forms of urticaria. An increased incidence has been reported during pregnancy (especially in the second half), at the onset of menopause, in atopic children, and in patients with Behçet disease. [6]
Dermographism can appear in persons of any age but is more common in young adults; the peak incidence is in the second and third decades. Whether a sexual variance in prevalence occurs is unclear. None has been consistently reported, though one study on dermographism in children reported a female predominance. [7] No racial variance in prevalence is known.
Simple dermographism is the most common variant, and patients with this form are asymptomatic. However, other forms are associated with pruritus, and this can significantly affect quality of life. Most people with dermographism are otherwise healthy. An association with thyroid disease has been described in some patients but remains controversial.
The natural history of symptomatic dermographism is unpredictable. It may last for months or years, or be present intermittently. In many patients, the condition gradually improves and clears after several years. Of the chronic urticarias, symptomatic dermographism appears to have the best prognosis in terms of clearance after 5 years (36%) and 10 years (51%). [8]
Reassure patients about the benign nature of the disorder, and inform them of the possible prolonged course. Explain the adverse effects of antihistamine therapy. In particular, warn patients about drowsiness, which is especially problematic when they are driving or handling machinery.
For patient education resources, see the Allergy Center and Skin, Hair, and Nails Center, as well as Hives and Angioedema.
Grimm V, Mempel M, Ring J, Abeck D. Congenital symptomatic dermographism as the first symptom of mastocytosis. Br J Dermatol. 2000 Nov. 143(5):1109. [Medline].
Taskapan O, Harmanyeri Y. Evaluation of patients with symptomatic dermographism. J Eur Acad Dermatol Venereol. 2006 Jan. 20(1):58-62. [Medline].
Wallengren J, Isaksson A. Urticarial Dermographism: Clinical features and response to psychosocial stress. Acta Derm Venereol. 2007. 87:493-8. [Medline].
Wu JJ, Huang DB, Murase JE, Weinstein GD. Dermographism secondary to trauma from a coral reef. J Eur Acad Dermatol Venereol. Nov 2006. 20:1337-8. [Medline].
Rahim KF, Dawe RS. Dermatomyositis presenting with symptomatic dermographism and raised troponin T: a case report. Journal of Medical Case Reports. July 2009. 3:7319. [Medline]. [Full Text].
Dinc A, Karaayvaz M, Caliskaner AZ, Pay S, Erdem H, Turan M. Dermographism and atopy in patients with Behcet’s disease. J Investig Allergol Clin Immunol. 2000 Nov-Dec. 10(6):368-71. [Medline].
Martorell A, Sanz J, Ortiz M, Julve N, Cerda JC, Ferriols E. Prevalence of dermographism in children. J Investig Allergol Clin Immunol. 2000 May-Jun. 10(3):166-9. [Medline].
van der Valk PG, Moret G, Kiemeney LA. The natural history of chronic urticaria and angioedema in patients visiting a tertiary referral centre. Br J Dermatol. 2002 Jan. 146(1):110-3. [Medline].
Lambiris A, Greaves MW. Dyspareunia and vulvodynia: unrecognised manifestations of symptomatic dermographism. Lancet. 1997 Jan 4. 349(9044):28. [Medline].
Matthews CN, Warin RP. Cold urticaria and cold precipitated dermographism. Br J Dermatol. Jan 1970. 82:91. [Medline].
Jedele KB, Michels VV. Familial dermographism. Am J Med Genet. 1991 May 1. 39(2):201-3. [Medline].
Golberg O, Johnston GA, Wilkinson M. Symptomatic dermographism mimicking latex allergy. Dermatitis. 2014 Mar-Apr. 25:101-3. [Medline].
Hawkey S, Abdul Ghaffar S. Glove-related urticaria: an increasing occupational problem amongst health care workers. Br J Dermatol. 2015 Nov 17. Epub ahead of print:[Medline].
Schoepke N, Mlynek A, Weller K, Church MK, Maurer M. Symptomatic dermographism: an inadequately described disease. J Eur Acad Dermatol Venereol. 2015 Apr. 29(4):708-12. [Medline].
Sharpe GR, Shuster S. In dermographic urticaria H2 receptor antagonists have a small but therapeutically irrelevant additional effect compared with H1 antagonists alone. Br J Dermatol. 1993 Nov. 129(5):575-9. [Medline].
Maurer M, Metz M, Brehler R, et al. Omalizumab treatment in patients with chronic inducible urticaria: A systematic review of published evidence. J Allergy Clin Immunol. 2018 Feb. 141:638-649. [Medline].
Maurer M, Schuetz A, Weller K, et al. Omalizumab is effective in symptomatic dermographism-results of a randomised placebo-controlled trial. J Allergy Clin Immunol. 2017 Sept. 140:870-873. [Medline].
Metz M, Altrichter S, Ardelean E, at al. Anti-Immunoglobulin E Treatment of Patients with Recalcitrant Physical Urticaria. Int Arch Allergy Immunol. 2011. 154:177-180. [Medline].
Vieira Dos Santos R, Locks Bidese B, Rabello de Souza J, Maurer M. Effects of Omalizumab in a patient with three types of chronic urticaria. Br J Dermatol. 2013 Sep 14. [Medline].
Metz M, Ohanyan T, Chruch MK, Maurer M. Retreatment with omalizumab results in rapid remission in chronic spontaneous and inducible urticaria. JAMA Dermatol. 2014 Mar. 150(3):288-90. [Medline].
Borzova E, Rutherford A, Konstantinou GN, Leslie KS, Grattan CE. Narrowband ultraviolet B phototherapy is beneficial in antihistamine-resistant symptomatic dermographism: A pilot study. J Am Acad Dermatol. Sept 2008. 59:752-7. [Medline].
Grattan CEH, Kobza Black A. Urticaria and mastocytosis. Burns DA, Breathnach SM, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology. 7th ed. London, England: Blackwell Science; 2004. Vol 3: 47.1-47.37.
Simone Laube, MD, MRCP Consulting Staff, Department of Dermatology, Borders General Hospital, Melrose and Western General Hospital, Edinburgh
Simone Laube, MD, MRCP is a member of the following medical societies: British Association of Dermatologists, Scottish Dermatological Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Celgene.
Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.
Shyam Verma, MBBS, DVD, FAAD Adjunct Clinical Assistant Professor, Department of Dermatology, University of Virginia, State University of New York at Stonybrook, Penn State University
Shyam Verma, MBBS, DVD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MDis a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.
Elsbeth Young, MD, FRCP Consulting Staff, Department of Dermatology, Amersham Hospital and Wycombe General Hospital, UK
Disclosure: Nothing to disclose.
Dermographism Urticaria
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