Segmental urticaria triggered by alcohol consumption.

Introduction

Urticaria is a common skin disorder characterized by rapid development of edema of the epidermis (hives) that might be accompanied by angioedema. Although individual skin lesions resolve within 24 hours, when the overall condition persists for more than 6 weeks, it is classified as chronic urticaria. Chronic urticaria is classified as spontaneous urticaria when a cause cannot be identified or induced urticaria when a trigger is known. The role of alcohol as a trigger for generalized urticaria has been previously highlighted, but the pathogenesis remains poorly understood. Here we report the first case, to our knowledge, of segmental urticaria triggered by alcohol consumption.

Case report

A 19-year-old female bar worker presented to the dermatology outpatient department with a 6-month history of localized erythema and swelling that always affected the right side of her neck, anterior chest wall, and right arm. Her symptoms occurred within seconds of drinking alcoholic beverages. Complete resolution of symptoms was noted 10 minutes after she stopped consuming alcohol. Following patient's consent, an oral challenge test was performed with 440 mL of 5% alcohol cider. Confirmation of her symptoms, as captured in the video, revealed a localized urticarial rash affecting only the areas that she described (right side of neck, anterior chest wall, and right arm). The symptoms would present even if touching alcohol as part of her work.

Clinical history, physical examination, and laboratory investigations excluded common causes of chronic recurrent urticaria. She was not on any long-term medication and reported no history of atopy. Her symptoms were not related to physical stimuli, cold, heat, or sun exposure. Additionally, causes of skin flushing not related to alcohol consumption, namely, hypoglycemia, hyperthyroidism, early menopause, and carcinoid, were considered and excluded.

Investigations found normal full blood count and renal, liver, and thyroid function. Her medical history included chronic pelvic pain that was investigated with a laparoscopy that was normal. She had normal menses and no symptoms of diarrhea. Two skin biopsy sections were obtained, one from normal skin and one from skin affected from the urticarial rash. The histologic findings were nonspecific, showing superficial perivascular infiltrate of lymphocytes and no evidence of mast cell infiltrate. Treatment intervention involved 10 mg of cetirizine taken prior to the consumption of alcohol that settled her symptoms. The urticarial symptoms completely settled during pregnancy when the patient had stopped consuming alcohol. Postpregnancy they returned as she resumed her consumption of alcohol. These also settled with antihistamines.

Discussion

Alcohol consumption has been implicated as a cause for urticaria in several case reports,, but the pathogenesis of mast cell activation remains to be elucidated. The acute and chronic toxicologic effects after alcohol misuse are well known. Less known adverse reactions to alcohol use, including urticaria, have been the subject of a recent study that classified them as immunologic and nonimmunologic reactions. Specifically, 3 mechanisms were proposed with regard to urticarial reactions to alcohol: (1) the direct action of ethanol on mast cells causing them to degranulate, (2) allergenic potential of ethanol metabolites, and (3) the activation of prostaglandin and endogenous opioid receptors.

This is the first case, to our knowledge, of segmental urticaria, consistently affecting the same body surface, induced by alcohol consumption. The authors would like to raise awareness of urticarial symptoms provoked by oral consumption or contact with alcohol but also remind clinicians to be vigilant in ruling out other potential causes of these symptoms.