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ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 144-148

Importance of dermoscopy in differentiating common urticaria and urticarial vasculitis: A randomized control study


Department of Dermatology, Venerelogy and Leprology, S. Nijalingappa Medical College, Bagalkot, Karnataka, India

Date of Submission23-May-2020
Date of Decision13-Jul-2020
Date of Acceptance03-Feb-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Mahajabeen Saheb Patel Madarkar
Department of Dermatology, Venerelogy and Leprology, S. Nijalingappa Medical College, Bagalkot, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_82_20

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  Abstract 


Background: Urticarial vasculitis is a clinicopathological entity that overlaps with common urticaria, and histopathological diagnosis is required for differentiation between them. Objectives: To determine, for the first time, if skin surface microscopy can aid in the clinical differentiation between common urticaria and urticarial vasculitis in daily practice. Materials and Methods: Lesions in 20 patients with a clinical diagnosis of urticaria were studied. All urticarial lesions were subjected to dermoscopy, skin biopsy, and histopathological examination to confirm the diagnosis. Dermoscopy was performed using Derm Lite 3 dermoscope and images captured were anyalysed. Clinical images were taken. A punch biopsy was performed in all patients. Statistical analysis was done. Results: In 11 patients diagnosed clinically as chronic urticaria, on dermoscopy showed red lines in 9(45%), red dots in 2 (10%) and structureless areas in 8(40%) patients. In 9 patients diagnosed as urticarial vasculitis clinically, on dermoscopy revealed purpuric dots in 8(40%) and purpuric globules in 5(25%) patients. Conclusion: We conclude that in our setting dermoscopy significantly facilitates the detection, diagnosis and differentiation of common urticaria and urticarial vasculitis.

Keywords: Common urticaria and urticarial vasculitis, Dermoscopy, Histopathology


How to cite this article:
Patel Madarkar MS. Importance of dermoscopy in differentiating common urticaria and urticarial vasculitis: A randomized control study. Clin Dermatol Rev 2021;5:144-8

How to cite this URL:
Patel Madarkar MS. Importance of dermoscopy in differentiating common urticaria and urticarial vasculitis: A randomized control study. Clin Dermatol Rev [serial online] 2021 [cited 2021 Nov 27];5:144-8. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/144/324577




  Introduction Top


Common urticaria (CU) is described as a transient, intensely pruritic, circumscribed, raised, erythematous plaques often with central pallor due to transient dermal edema and vasodilatation. It is classified as acute and chronic urticaria by nature of its chronicity. A urticaria is considered acute when it lasts for <24 h. Chronic urticaria is defined by recurrent episodes occurring at least twice a week for 6 weeks. Histologically, CU is characterized by dermal or subcutaneous edema and sparse or dense perivascular lymphocytic infiltrate, along with neutrophils and eosinophils.[1] CU is dermoscopically characterized by a red, reticular network of linear vessels, which may be surrounded by an area devoid of vessels, corresponding to dermal edema.[2]

Urticarial vasculitis (UV) is a clinicopathologic entity characterized clinically with urticarial lesions and disclosing histopathologically leukocytoclastic vasculitis of small vessels, mainly involving postcapillary venules.[3],[4] Recognizing UV is crucial given a possible association with systemic features. UV is classified into hypocomplementemic UV (HUV) and normocomplementemic UV.[3] This condition is idiopathic in many patients, but can also occur in the context of autoimmune disorders, infections, drug reactions, or as a paraneoplastic syndrome.[5]

CU and UV clinically overlap, and hence biopsy is required for differentiation between them. This discrimination is important because UV may be a cutaneous manifestation of an underlying connective tissue disorder, such as systemic lupus erythematosus, HUV syndrome, Sjogren's syndrome, and mixed cryoglobulinemia.[6]

The study aims to provide a noninvasive method of differentiating between CU and UV.


  Materials and Methods Top


The study was conducted in one of the tertiary care centers of South India. It was a randomized control study. Informed written consent was obtained from all the patients under the study. Ethical clearance was obtained from the institutional ethical committee.

Twenty consecutive patients with a clinical diagnosis of urticaria were studied. All urticarial lesions were subjected to dermoscopy, skin biopsy, and histopathological examination to confirm the diagnosis. A DermLite 3 dermoscope (3Gen Inc. 31521 Rancho Viejo Road, Suite 104 San Juan Capistrano, CA 92675, USA) was employed. A Sony digital camera (Sony Cyber shot camera DSC W800; Sony Electronics Inc., San Diego, CA, USA, with 14 Mega pixels) was attached to save the images. Both polarized and nonpolarized modes were used, and ultrasound gel was utilized as an interface medium.

Data were tabulated into a Microsoft Excel® sheet. Proportions and percentages were used for representing the data.

Statistical analysis was performed with Fisher's exact test. The most significant features were used for evaluating the differentiation between CU and UV.


  Results Top


A total of 20 patients were included in this study, of which 11 (55%) were male and 9 (45%) were female [Table 1].
Table 1: Age distribution of the patients

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The most common age group of presentation with urticaria was between 30 and 45 years in 8 patients (40%), followed by 7 patients (35%) in the age group of 15–30 years among [Table 2] in this study.
Table 2: Sex distribution of the patients

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Of the 20 patients, 11 patients were diagnosed clinically as CU. Dermoscopy of these patients revealed the presence of red lines in 9 (45%), red dots in 2 (10%), and structureless areas in 8 (40%) patients [Figure 1], [Figure 2]a and [Figure 2]b, [Figure 3].
Figure 1: Showing wheal suggestive of common urticaria

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Figure 2: (a) A reticulated vessels under dermoscopy suggestive of urticaria (b) Erythema under dermoscopy suggestive of urticarial

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Figure 3: Showing distribution of dermoscopic findings (reddish lines, avascular areas) in common urticaria

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Biopsy of these 11 patients showed a perivascular lymphocytic infiltrate in 9 patients (45%) and dermal edema in 8 patients (40%) [Figure 4] and [Table 3]. In those patients who showed red-lines or a negative pattern (areas devoid of vascular findings) did not reveal any features of vasculitis. Although some of these patients showed perivascular neutrophilic infiltrates, none fulfilled the criteria for vasculitis which includes the presence of nuclear dust, fibrin deposition within the vessel wall or erythrocyte extravasation.
Table 3: Distribution of dermal edema and perivascular lymphocytic infiltrate on histopathology

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Figure 4: Showing dermal edema and perivascular lymphocytic infiltrate on histopathology (H and E stain ×100)

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Nine of the total 20 patients were diagnosed clinically as UV, on dermoscopy revealed the presence of purpuric dots and purpuric globules in 8 (40%) and 5 (25%) patients, respectively [Figure 5], [Figure 6], [Figure 7].
Figure 5: Showing wheal suggestive of urticarial vasculitis

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Figure 6: Showing dermoscopic findings-purpuric dots, purpuric globules in urticarial vasculitis

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Figure 7: Showing distribution of dermoscopic findings (purpuric dots, purpuric globules) in common urticaria

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Histopathology of these 9 patients, showed dermal edema in 9 (55%) patients, inflammatory infiltrate (not of perivascular involvement) in 7 (35%) patients, perivascular neutrophilic inflammatory infiltrate in 9 (45%) patients, and karyorrhexis in 7 (35%) patients [Figure 8] and [Table 4]. The perivascular infiltrate is primarily composed of neutrophils and rarely lymphocytes and eosinophils mainly involving the dermal capillaries.
Table 4: Distribution of perivascular and interstitial infiltrates with karyorrhexis histopathology

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Figure 8: Showing Perivascular and interstitial infiltrates with karyorrhexis

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Dermoscopy and histopathological correlation

The structureless areas seen in CU correlates with the intense dermal edema which obscures the vascular pathology on histopathology. Ectatic, horizontal, dermal subpapillary vessels on histopathology correlates with the red reticular lines on dermoscopy. Purpuric globules correlate with the extravasated and degraded red blood cells in UV.


  Discussion Top


Dermoscopy is a noninvasive skin magnification technique, which allows a real in vivo subclinical exploration of the skin. Dermoscopy improves and completes clinical examination by revealing morphologic structures that are scarcely visible or invisible on the standard naked-eye physical examination.

The value of dermoscopy for the differentiation between CU and UV has been proposed but in few small series. In the present study, we studied the dermoscopic patterns of patients presenting with CU and UV and correlated it histopathologically.

CU is characterized by the rapid appearance of wheals which may be accompanied by angioedema. A wheal consists of three classical features:

  1. A central swelling of variable size, almost invariably surrounded by a reflex erythema;
  2. Associated itching or sometimes burning;
  3. Fleeting nature, with a duration of usually 1–24 h.[3]


UV represents a spectrum of disease that is associated clinically with urticaria, but because of the vessel damage, it differs histologically from urticaria. When compared with other cutaneous leukocytoclastic vasculitis, UV most commonly involves the postcapillary venules, and it is considered to be a Type III hypersensitivity reaction.[5]

Some of the most common systemic manifestations of UV include the so-called “AHA syndrome” which consists of arthralgias and arthritis (A), hives (H), and angioedema (A).[6]

Classic clinical criteria for UV are: Persistence of individual lesions, lasting more than 24 h; presence of tenderness or a painful/burning sensation; purpura or dusky discoloration of the skin and resolution of lesions with residual hyperpigmentation. However, because clinical characteristics of UV may overlap with those of CU, confirmation of the diagnosis requires a lesional skin biopsy.

There is no definitive clinical or histopathologic distinction between urticaria and UV, and some patients with clinically apparent CU show the evidence of vasculitis histologically.[7] In support of this, a recent evidence suggests that UV may be an underlying process in 20% of patients with clinical presentations of CU resistant to treatment with antihistamines.[8]

Phanuphak et al.,[10] found that in 42 patients included in the study with chronic urticaria, twenty patients (52%) of patients had vasculitis on biopsy.

In our study also, there were three patients originally diagnosed with CU had vasculitis on biopsy.

Dermoscopy is a simple, rapid, reliable, and noninvasive diagnostic tool that helps to visualize morphological features that cannot be seen with naked eyes, thus representing a link between macroscopic clinical dermatology and microscopic dermatopathology. Thus, structure seen with dermoscopy equate to a histopathological correlate and therefore an understanding of this relationship will help in accurate diagnosis.[10]

Patients diagnosed with CU on dermoscopy revealed the presence of red lines in 9 (45%), red dots in 2 (10%), and structureless areas in 8 (40%) patients. Biopsy of these 11 patients showed a perivascular lymphocytic infiltrate in 9 (45%) patients and dermal edema in 8 (40%) patients.

CU dermoscopically exhibits prominent reticular red lines. These red lines correspond histologically with ectatic, horizontal, subpapillary vessels and are different from vascular red dots which represent papillary vessels. Lesions of CU may also show structureless avascular areas, devoid of vascular findings, representing areas with prominent dermal edema[11],[12] [Table 5].
Table 5: Dermoscopic correlation with histopathology

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Nine patients diagnosed clinically as UV, on dermoscopy revealed the presence of purpuric dots and purpuric globules in 8 (40%) and 5 (25%) patients, respectively. Histopathologically of these 9 patients showed dermal edema in 11 (55%) patients, inflammatory infiltrate (not of perivascular) in 7 (35%) patients, perivascular neutrophilic inflammatory infiltrate in 9 (45%) patients, and karyorrhexis in 7 (35%) patients. As we performed biopsy in patients presenting with lesions <48 h, neutrophilic perivascular infiltrates predominated.

According to the definition of vasculitis, it includes four criteria (fibrin deposits, nuclear dust, neutrophilic infiltrates, and erythrocyte extravasation).[13] As regards to histological differentiation between CU and UV lesions, nuclear dust and dermal hemorrhages have been considered the most specific differential criteria, being present only in UV and not in CU.

UV dermoscopically revealed purpuric dots or globules in a patchy orange-brown background. These structures were due to extravasation and degradation of red blood cells. Red lines and purpuric globules are not specific to urticaria and UV, respectively; however, the recognition of these structures will help as a first-line clinical screening tool for discriminating between CU and UV in daily practice.

In conclusion, dermoscopy helps the clinical discrimination between CU and UV by aiding the clinical examination. Dermoscopy enhances visualization of subclinical purpuric patches, which are highly indicative of an underlying vasculitis when confronted with CU. This technique may contribute to optimize decisions regarding biopsy in patients with urticarial rashes, so commonly attended in daily clinical practice.


  Conclusion Top


Dermoscopy plays the pivotal role in diagnosis and differentiation of CU from UV. It helps in early diagnosis of UV when patients present within 24 h of appearance of the lesions and thence early treatment of these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pigatto PD, Valsecchi RH. Chronic urticaria: A mystery. Allergy 2000;55:306-8.  Back to cited text no. 1
    
2.
Vázquez-López F, Maldonado-Seral C, Soler-Sánchez T, Perez-Oliva N, Marghoob AA. Surface microscopy for discriminating between common urticaria and urticarial vasculitis. Rheumatology (Oxford) 2003;42:1079-82.  Back to cited text no. 2
    
3.
Sunderkötter CH, Zelger B, Chen KR, Requena L, Piette W, Carlson JA, et al. Nomenclature of cutaneous vasculitis: Dermatologic addendum to the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheumatol 2018;70:171-84.  Back to cited text no. 3
    
4.
Caproni M, Verdelli A. An update on the nomenclature for cutaneous vasculitis. Curr Opin Rheumatol 2019;31:46-52.  Back to cited text no. 4
    
5.
Dincy CV, George R, Jacob M, Mathai E, Pulimood S, Eapen EP. Clinicopathologic profile of normocomplementemic and hypocomplementemic urticarial vasculitis: A study from South India. J Eur Acad Dermatol Venereol 2008;22:789-94.  Back to cited text no. 5
    
6.
Tosoni C, Lodi-Rizzini F, Cinquini M, Pasolini G, Venturini M, Sinico RA, et al. A reassessment of diagnostic criteria and treatment of idiopathic urticarial vasculitis: A retrospective study of 47 patients. Clin Exp Dermatol 2009;34:166-70.  Back to cited text no. 6
    
7.
Varadarajulu S. Urticaria and angioedema. Controlling acute episodes, coping with chronic cases. Postgrad Med 2005;117:25-31.  Back to cited text no. 7
    
8.
Bauersachs RM, Lössner F. The poor man's capillary microscope. A novel technique for the assessment of capillary morphology. Ann Rheum Dis 1997;56:435-7.  Back to cited text no. 8
    
9.
Phanuphak P, Kohler PF, Stanford RE, Schock, Carr RI, Claman HN et al. Vasculitis in chronic urticaria. J Allergy Clin Immunol 1980;65:436 44.  Back to cited text no. 9
    
10.
Krause K, Mahamed A, Weller K, Metz M, Zuberbier T, Maurer M. Efficacy and safety of canakinumab in urticarial vasculitis: An open label study. J Allergy Clin Immunol 2013;132:751-4.  Back to cited text no. 10
    
11.
Zalaudek I, Argenziano G, Di Stefani A, Ferrara G, Marghoob AA, Hofmann-Wellenhof R, et al. Dermoscopy in general dermatology. Dermatology 2006;212:7-18.  Back to cited text no. 11
    
12.
Vázquez-López F, Fueyo A, Sánchez-Martín J, Pérez-Oliva N. Dermoscopy for the screening of common urticaria and urticaria vasculitis. Arch Dermatol 2008;144:568.  Back to cited text no. 12
    
13.
Mehregan DR, Hall MJ, Gibson LE. Urticarial vasculitis: A histopathologic and clinical review of 72 cases. J Am Acad Dermatol 1992;26:441-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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