Friday, January 11, 2008

Papular Unticaria

Abstract: 20 yo student with pruritic papules for three weeks

History: While on a ski trip in New Mexico, this young woman developed a few pruritic papules around the neck. Over the next few days, these spread to torso and extremities. Some of the lesions were grouped in a "breakfast, lunch and dinner" distribution. She is in excellent health: a ski racer.

Exam: 1/3/08: There were 40 - 60 6 - 8 mm in diameter erythematous papules on torso, upper and lower extremities and to a lesser extent face. No lesions on doubly covered areas. After treatment with topical steroids this improved, but then flared around a week later.
1/10/08: Many new papules, neck, torso, extremities. No longer "breakfast, lunch and dinner" distribution.

Lab: CBC pending

Pathology: Consistent with arthropod bites or drug reaction. Will add photos later. Specimen shows parakeratosis, epidermal hyperplasia with focal eosinophilic exocytosis and a moderately dense superficial and mid perivascular interstitial lymphocytic infiltrate with scatterred eosinophils.

Diagnosis: Papular Urticaria (PU)

Questions: This woman is a competitive athlete. She does not want to take prednisone while racing. The lesions are very widespread and potent corticosteroid creams do not give much relief. Hydroxizine, too, will blunt her competitive edge. What would you recommend.

Reference: There was a good review of PU by Hernandez and Cohen in Pediatrics in 2006. "Insect bite-induced hypersensitivity and the SCRATCH principles: a new approach to papular urticaria." It is available in full-text: Hernandez/Cohen

Your thoughts and suggestions are welcome.


  1. I am not sure but i think you will see good effect with combination of Dapsone with Zyrtec as peros and Elidel with corticosteroid cream as topical.

  2. Rick SontheimerJanuary 12, 2008

    Any chance she brought bed bugs home with her in her luggage or suitcase?

  3. Rick SontheimerJanuary 13, 2008

    I think papular urticaria in kids and "subacute prurigo" in adults might be linked and represent curious patterns of hypersensitivity that might involve some interesting immunological mechanisms (eg, recirculating cytotoxic T cells that home to some areas of skin distant to the original stimulis of the hypersensitivity state).

  4. Professor SharquieJanuary 13, 2008

    This is bed bug papular urticaria.The bedbugs usually live in woody things and only appear late at night to feed on victim blood.So these insects should be only seen on beds only at night while they hide and sleep during day.So please ask the patient to look for these bugs and control them by special insecticide.This disease is endemic in iraq since 1982 that introduced to Baghdad by Egyptian workers.
    khalifa Sharquie, Baghdad, Iraq

  5. in Habif for itch- paste: from 1 teaspoon of water and 1 tespoon of meat tenderizer.
    for protection against insect bites: 75-150mg vit B1 PO daily.

  6. you can test topical calamine and menthol along with mild topical steroid


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