Photo Quiz

An Activity-Induced Rash

 

Am Fam Physician. 2016 Nov 1;94(9):735-736.

A 50-year-old man presented with a history of rashes on his back, chest, and upper extremities that appeared after physical activity, such as exercise or yard work. The rashes began five months earlier. He reported occasional itching and hives that appeared after scratching. He did not have nausea, vomiting, choking sensation, or difficulty breathing. He had not used any new lotions, soaps, cologne, or detergents. He had a history of hyperlipidemia, for which he was taking simvastatin (Zocor). His family history was unremarkable.

On physical examination, he initially did not have a skin rash or lesions. He had normal skin turgor and temperature. When pressure was applied to the skin, an erythematous patch formed (Figure 1) and progressed to a wheal after approximately five minutes (Figure 2).

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Figure 1.


Figure 1.

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Figure 2.


Figure 2.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Cholinergic urticaria.

B. Fixed drug reaction.

C. Irritant contact dermatitis.

D. Urticarial vasculitis.

Discussion

The answer is A: cholinergic urticaria. Symptoms typically present approximately five to 10 minutes after an inciting event, such as eating spicy foods, exercise, feeling intense emotions, or bathing in hot water. Tingling, pruritus, or a burning sensation may occur with the presence of lesions. The patient also had dermographism, which is the result of histamine release when pressure is applied to the skin.1

The diagnosis of cholinergic urticaria is clinical, based on history and physical examination findings. It can be confirmed with passive warming, using water or an exercise challenge, to reproduce symptoms.2 The patient had the classic history findings of raised lesions occurring after passive warming of the skin during exercise or activity. Lesions typically arise on the neck and upper thorax but can spread to the entire body.

The lesions usually resolve in 15 to 20 minutes unless there are multiple lesions, which may remain for hours. Management of the condition includes activity and behavioral modification, such as avoiding hot water or exercise in hot weather. Patients can use prophylactic antihistamine treatment prior to exercise or strenuous activities.

A fixed drug eruption is a localized, cutaneous reaction that occurs hours to days after a drug is ingested. Typically, lesions are nonpruritic, solitary, and well demarcated. They present as edematous, violaceous, hyperpigmented plaques. The most common causative agents include antibiotics, such as trimethoprim-sulfamethoxazole and penicillin; salicylates; nonsteroidal anti-inflammatory drugs; barbiturates; and food coloring.3 The lesions will reappear in the same location if there is a new exposure to the agent.

Irritant contact dermatitis typically presents as burning, pruritic, scaling lesions with less distinct borders than those that occur after contact with a foreign substance.4 Irritant contact dermatitis can be a result of skin injury, cytotoxic effects, or inflammation from contact with an irritant.4 A common presentation involves dry and fissured skin on the hands.

Urticarial vasculitis is a type III hypersensitivity that typically presents as painful wheals that last more than 24 hours. The lesions may develop residual hyperpigmentation or purpura. Although the cause is unknown, urticarial vasculitis may be related to rheumatologic diseases, such as lupus; use of medications, such as penicillin and nonsteroidal anti-inflammatory drugs; and viruses, such as hepatitis B and C.5

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Summary Table

ConditionCharacteristics

Cholinergic urticaria

Raised lesions caused by passive warming of the skin during exercise or with exposure to hot water; typically occurs on the neck and upper thorax

Fixed drug reaction

A localized nonpruritic, solitary, well-demarcated lesion presenting as edematous, violaceous, hyperpigmented plaques

Irritant contact dermatitis

Burning, pruritic, scaling lesions with indistinct borders; commonly involves the hands

Urticarial vasculitis

Painful wheals that last for more than 24 hours

Summary Table

ConditionCharacteristics

Cholinergic urticaria

Raised lesions caused by passive warming of the skin during exercise or with exposure to hot water; typically occurs on the neck and upper thorax

Fixed drug reaction

A localized nonpruritic, solitary, well-demarcated lesion presenting as edematous, violaceous, hyperpigmented plaques

Irritant contact dermatitis

Burning, pruritic, scaling lesions with indistinct borders; commonly involves the hands

Urticarial vasculitis

Painful wheals that last for more than 24 hours

The views expressed herein are those of the authors and do not represent the official views of the Department of Defense or the Army Medical Department.

Address correspondence to Shane L. Larson, MD, at shane.l.larson.mil@mail.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Montgomery SL. Cholinergic urticaria and exercise-induced anaphylaxis. Curr Sports Med Rep. 2015;14(1):61–63....

2. Hosey RG, Carek PJ, Goo A. Exercise-induced anaphylaxis and urticaria. Am Fam Physician. 2001;64(8):1367–1372.

3. Flowers H, Brodell R, Brents M, Wyatt JP. Fixed drug eruptions: presentation, diagnosis, and management. South Med J. 2014;107(11):724–727.

4. Usatine RP, Riojas M. Management of contact dermatitis. Am Fam Physician. 2010;82(3):249–255.

5. Schaefer P. Urticaria: evaluation and treatment. Am Fam Physician. 2011;83(9):1078–1084.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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