Chronic Urticaria & Angioedema successfully treated by Thyroxin
Thaer Douri, M.D,
Dermatologist,
Hama - Syria
Case Report
• A woman aged 30 years, Pharmacist,
presented with a three years history of
urticaria & angioedema which was
treated previously by the classical
treatment without benefit .
Paraclinical Studies
• Routine laboratory investigation : Normal
• ANA, C1, C4, C3 : Normal.
• Abdominal Echogarphy : Normal.
• Chest X-Ray : Normal.
• The patient was initially treated by: Antihistamines,
Unicycline,
Nystatine,
Diet. Transient improvement
Follow up
• Although T3, TSH were normal, We decided to
treat the patient by L - Thyroxin 100 microgram
daily.
RESULT • Magic improvement .
• The patient was symptom- free during
treatment .
• Recurrence when the patient stopped the
treatment .
Review of Medical Literature
Angioedema
Causes :1-Food .
2-Drugs .
3-Hereditary .
4-Idiopathic .
Hereditary angioedema
• HAE 3 types :1- plasma concentration of c1-inhibitor are 5-30% of
normal , and C4 concentration is low 2-C1-inhibitor normal or raised , bet it is dysfunctional,
and C4 concentration is low.3-both of C1-inhibitor ,and C4 concentration are normal
The clinical features of three variants of HAE are similar .
YEAR BOOK OF DERMATOLOGY 2001 P59
Management of chronic urticaria
remove identifiable cause
Non drug therapy pharmacological therapy
J.A.A.D May 2002
Non drug therapy
• General advice: cooling lotion
• Avoidance aggravating factor : avoid
aspirin,NSAIDs,codein,morphine,ACE
inhibitors – minimize stress,overheating,
alcholic.
• Diet
J.A.A.D May 2002
pharmacological therapy
First line non or low sedating H1 antihistamine .
Add sedating H1 antihistamine at night.
Add H2 antagonist
J.A.A.D May 2002
pharmacological therapy
second line Corticosteroids ( short term use only )
Epinephrine (severe throat angioedema or anaphlaxis)
Other
J.A.A.D May 2002
pharmacological therapy
Third line
Immunotherapy
J.A.A.D May 2002
Leznoff described (1) :• 140 cases of urticaria, 17 ( 12,1 % ) have elevated
( ANTIBODY MICROSOMAL THYROID ),
• 8 patients have a goiter or thyroid dysfunction,
• 17 angioedema ( 15 f ),
• Control : 447 , only 27 ( 5,6%) have (ANTIBODY
MICROSOMAL THYROID ).
J . A . D FEBRAURY 1999 . P 229
Leznoff described (2) :
• 90 patients of 624 (14,4 %) , with chronic
Urticaria & Angioedem have thyroid
autoimmunity disease,
• Control only (6%).
J . A . D FEBRAURY 1999 . P 229
Gazi university, Turkey :
• 94 with Urticaria & Angioedema were studied,
• 11 (11,7%) have ( Thyroglobulin antibodies )
• 9 (9,75%) have ( Thyroid microsomal antibodies).
• 6 of 11 have thyroid dysfunction, and 5 were euthyroid,
• Control :( 80 ) only( 3,7%) have both antibodies.
Int J Dermatol 1997 Mar;36(3):187-90
Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity.
• Antithyroglobulin and antiperoxidase antibodies were measured in 170 consecutive patients with CIU.
• Twenty-five (14.7%) had an antithyroglobulin or antiperoxidase antibody levels > 180 lU/ml and all but three were women.
J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5
• Twenty patients with CIU and thyroid autoimmunity were treated with levothyroxine sodium if hypothyroidism or normal thyroid function were present (18 patients) and with methimazole if hyperthyroidism was detected (two patients)
J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5
Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity.
• Urticaria resolved rapidly in two patients with Graves' disease.
• The clinical response of urticaria to levothyroxine sodium treatment was good in 15 patients and partial in two, whereas only one patient showed no improvement in clinical score (p < 0.0005).
• No changes in the antithyroglobulin or antiperoxidase levels were detected.
J Investig Allergol Clin Immunol 2000 Nov-Dec;10(6):342-5
Successful treatment of chronic idiopathic urticaria associated with thyroid autoimmunity.
REMARKS• The mechanism by which thyroid autoimmunity
is associated with Urticaria is poorly understood.
• L - Thyroxin was used to treat (C.U.A) for the
first time by Leznoff in 1983.
• The mechanism is an enigma .
• Hyperthyroidism and Hypothyroidism may be the
cause of itching .
• L-Thyroxin may cause Urticaria .
J . A . D FEBRAURY 1999 . P 229
GUIDELINE TREATMENT • Screen for Thyroid autoimmunity,
• Treatment with L - Thyroxin for (CUA) unresponsive
for classical treatment .
• T.S.H should be monitored after 4-6 weeks of the
initiation of therapy.
• If there is no benefit after 8 weeks, L- Thyroxin should
be stopped.
• The treatment must be stopped after 1-2 months of
recovery and reinitiated in the case of relapse
J . A . D FEBRAURY 1999 . P 229
REFERENCES
• J.A.A.D May 2002.
• J . A . D FEBRAURY 1999 . P 229.
• Int J Dermatol 1997 Mar;36(3):187-90.
• YEAR BOOK OF DERMATOLOGY 2001 P59.
• J Investig Allergol Clin Immunol 2000 Nov-
dec;10(6):342-5
Thank you