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July 2006

A Clinician's View of Urticarial Dermatitis

Arch Dermatol. 2006;142(7):927-947. doi:10.1001/archderm.142.7.932-a

I believe the term urticarial dermatitis caught on quickly with clinicians in Australia because the clinical picture of patients with the histologic features reported by Kossard et al1 has urticarial and eczematous features that vary in intensity over time, creating an oxymoronic quality that the name they coined captures nicely. The authors mention contact sensitivity as a mechanism capable of producing urticarial plaques, and Fung2 described a case of contact dermatitis to nickel that produced a solitary urticarial plaque with the histologic traits of a dermal hypersensitivity reaction that he termed urticarial papulosis. Kossard et al1 acknowledge that Fung2 has described the same process. More than 20 patients with such symptoms have been referred to me for patch testing, and I have yet to find a relevant contact allergen to account for the condition. The histologic traits in the cases I have evaluated have been more consistent with Fung's description2 of virtually no epidermal involvement and no neutrophils, just superficial and middermal lymphohistocytic infiltration accompanied by eosinophils. Some of these patients have abnormally high eosinophil counts in their blood and meet the criteria for having hypereosinophilic syndrome (>1500 eosinophils/mL3 for more than 6 months without other explanation). That syndrome was described in 1978 by Kazmierowski et al,3 who reported skin lesions that were erythematous and pruritic, papules and nodules, or urticaria and angioedema. It was pointed out that these skin changes may be the only manifestation of the hypereosinophilic syndrome.3 When urticarial dermatitis has been accompanied by systemic eosinophilia, I have considered it to be a benign, cutaneous form of the hypereosinophilic syndrome, and when the same eruption was present without systemic eosinophilia, I have previously used the term subacute prurigo. I find the term urticarial dermatitis far more descriptive. However, it should be noted that this same eruption has also been reported not only using these terms and those listed in the article by Kossard et al1, but also as grouping prurigo by Ofuji and Ogino4 and Ofugi precursor eruption by Fujii et al.5