High Yield Topics

Exercise-Induced Urticaria

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Ovid: 5-Minute Sports Medicine Consult, The


Exercise-Induced Urticaria
Mark Halstead
David T. Bernhardt
Basics
Description
  • Spectrum of allergic response to exercise ranging from itching, flushing, and cutaneous warmth to development of well-circumscribed wheals (large papular lesions with pale centers and an erythematous ring) and angioedema to severe anaphylactic shock
  • Elevation of serum histamine levels with exercise
  • Mast cell degranulation seen in skin biopsies suggesting immunoglobulin E–mediated sensitization
  • Described with almost any type of physical exercise
  • Distinguishable from cholinergic urticaria, which also has exercise as a possible trigger
  • Certain foods in combination with exercise may cause symptoms in susceptible individuals.
  • Synonym(s): Exercise-induced anaphylaxis; Hives
Epidemiology
  • Incidence and prevalence unknown
  • Predominant gender: Male = Female.
  • Predominant age: Seen more frequently in young adults but has been described as early as 4 yrs of age
Risk Factors
  • Atopic history (eczema, asthma, allergic rhinitis)
  • Other forms of physical allergy
  • Food allergy
General Prevention
  • Stop exercise with first onset of symptoms.
  • Avoid foods 6–8 hr before exercise. Exercising 1st thing in the morning after evening fast is preferable.
  • Avoid known problematic food or medication triggers for at least 12 hr before exercise.
  • Preventive antihistamine therapy may be useful.
  • Patients always should have an epinephrine kit with them while exercising; Benadryl also may be reasonable to have.
  • Exercising with a companion knowledgeable in CPR is recommended.
  • Recommend wearing medical alert device
Diagnosis
History
  • Diagnosis usually is made by history.
  • Initially patients describe generalized feeling of tingling, warmth, and itching.
  • May start as early as 5 min after initiating exercise or can occur after exercise has been completed
  • May have history of food or medication ingestion within previous 6–8 hr before exercise
  • Patients often (>50%) have atopic history (ie, eczema, asthma, allergic rhinitis).
  • Foods reported to be associated include eggs, lentils, shellfish, hazelnuts, wheat, peaches, apples, grapes, celery, and cheese sandwiches. Cases have been reported with many other foods.
  • Medications: NSAIDs, aspirin, antibiotics
  • Usually resolves within 30 min to 4 hr after exercise
  • Headaches may continue for up to 3–4 days after a severe reaction.
Physical Exam
  • Signs and symptoms:
    • Pruritus
    • Urticaria
    • Wheezing
    • Hypotension
    • Flushing
    • Angioedema
    • Headaches
    • Nausea
    • Choking
    • Profuse sweating
  • Physical examination:
    • Generally distinguished from cholinergic urticaria because larger (>10 mm) wheals are seen in exercise-induced urticaria, whereas fine punctate (<5 mm) lesions are seen in cholinergic urticaria
    • Wheals are not reproducible with generalized heat application or sweating, which is more characteristic of cholinergic urticaria, or cold application (ice cube) common to cold urticaria.
    • Respiratory examination may demonstrate stridor, wheezing, and retractions during acute attack.
    • Angioedema seen in more severe acute attacks
Diagnostic Tests & Interpretation
Lab
  • Not necessary in acute attacks
  • Allergy testing may be beneficial as an outpatient.
  • Positive skin testing does not always mean a cause-and-effect relationship. Suspicious positive skin tests may need to be followed by an exercise challenge because patients with positive food skin tests may not always develop urticaria with exercise and consumption of that food.
Differential Diagnosis
  • Physical urticarias (cold, dermographic, delayed pressure, solar, aquagenic, vibratory)
  • Cholinergic urticaria (induced by increased body temperature)
  • Exercise-induced asthma
  • Vocal cord dysfunction
  • Insect bites
  • Drug eruption
  • Urticaria pigmentosa
  • Systemic lupus erythematosus
  • Erythema multiforme

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Treatment
Medication
  • Epinephrine (Epi-Pen) 0.3 mg IM for severe anaphylactic reaction
  • Diphenhydramine (Benadryl) 25–50 mg PO q4–6h (children: 5 mg/kg/day divided q6–8h, not exceeding 300 mg/day)
  • Hydroxyzine (Atarax) 25–100 mg PO q6h (children: 2 mg/kg/day divided q6–8h)
  • During exercise, patients should carry an epinephrine kit (Epi-Pen) with them at all times.
  • H1 antihistamines as prophylaxis have shown mixed results (fexofenadine 60 mg PO b.i.d., loratadine 10 mg PO daily, and cetirizine 10 mg PO daily).
  • Cromolyn taken orally has been reported to be of some benefit.
  • H2 antihistamines may be of help (eg, cimetidine, ranitidine, and famotidine).
  • Doxepin, which has both H1– and H2-blocking abilities, may be of value.
Additional Treatment
General Measures
  • Acutely, care is targeted toward ensuring airway protection if severe anaphylaxis is present.
  • Trendelenburg position
Ongoing Care
Follow-Up Recommendations
Referral to an allergist may be beneficial for skin testing and controlled exercise challenge testing.
Additional Reading
Briner WW. Physical allergies and exercise. Clinical implications for those engaged in sports activities. Sports Med. 1993;15:365–373.
Briner WW, Sheffer AL. Exercise-induced anaphylaxis. Med Sci Sports Exerc. 1992;24:849–850.
Horan RF, Sheffer AL, Briner WW. Physical allergies. Med Sci Sports Exerc. 1992;214:845–848.
Kaplan AP. Allergy: principles and practice, 5th ed. St. Louis: Mosby-Year Book, 1998.
Nichols AW. Exercise-induced anaphylaxis and urticaria. Clin Sports Med. 1992;11:303–312.
Tilles S, Shocket A, Milgrum H. Exercise-induced anaphylaxis related to specific foods. J Pediatrics. 1995;27:587–589.
Tilles SA, Schocket AL. Food allergy: adverse reactions to foods and food additives. Cambridge: Blackwell Science, 1997.
Codes
ICD9
708.8 Other specified urticaria
Clinical Pearls
  • Exercise may be continued as long as precautions are taken by avoiding all food 6–8 hr before exercise and 12 hr after eating food suspected of causing reactions.
  • Epinephrine should be carried at all times with the patient when exercising, and a companion who knows CPR ideally would be exercising with the patient.
  • Patients who had severe life-threatening reactions likely need counseling to discuss curtailing exercise.
  • These reactions are not always preventable. Despite premedication with various antihistamines, patients still can develop urticarial lesions and have anaphylaxis.
  • Initiating antihistamine therapy on a daily basis for those who exercise frequently is a worthwhile start to hopefully reduce the number of occurrences of this phenomenon.
  • Each individual may react to different foods. Reported reactions occur more frequently with celery and shellfish, but also with hazelnuts, eggs, apples, peaches, grapes, wheat, and even cheese sandwiches.
  • Some patients have been reported to react to any food they eat, so avoid eating 4–6 hrs prior.
  • If a food seems to be a trigger a reaction, it is best to avoid that food for at least 12 hr before exercise.
  • It is reasonable to see an allergist for testing and an exercise challenge with suspicious food items.


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