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Urticaria and Erythema Multiforme


Urticaria and erythema multiforme (EM) are common cutaneous hypersensitivity reactions seen in children. They can be triggered by infection, although noninfectious causes also are prevalent. Although distinctly different entities, acute urticaria often is misdiagnosed as EM. Although urticaria usually is an isolated finding, urticaria and urticarial dermatoses can be seen in several syndromes and disorders such as papular urticaria, urticarial vasculitis, and the cryopyrin-associated periodic syndromes (CAPSs).

Urticaria

Etiologic Agents

Acute and chronic forms of urticaria have been attributed to numerous bacterial, viral, fungal, and other infectious agents ( Box 71.1 ). Noninfectious causes and associations include foods, medications, physical stimuli, aeroallergens, and systemic diseases ( Box 71.2 ).

BOX 71.1
Infectious Agents Associated With Urticaria

Bacteria

  • Borrelia burgdorferi (erythema chronicum migrans)

  • Chlamydophila pneumoniae

  • Escherichia coli

  • Helicobacter pylori

  • Neisseria gonorrhoeae

  • Neisseria meningitidis

  • Pseudomonas aeruginosa

  • Shigella sonnei

  • Streptococcus pyogenes a

    a Most common.

  • Yersinia enterocolitica

Fungi

  • Candida albicans

  • Cladosporium spp.

  • Coccidioides immitis

  • Histoplasma capsulatum

  • Candida glabrata

  • Trichophyton spp.

Helminths

  • Ancylostoma duodenale

  • Anisakis simplex

  • Ascaris lumbricoides

  • Echinococcus spp.

  • Enterobius vermicularis

  • Fasciola hepatica

  • Necator americanus

  • Onchocerca volvulus

  • Schistosoma spp.

  • Strongyloides stercoralis

  • Toxocara canis

  • Trichinella spiralis

  • Trichobilharzia spp. (avian blood flukes)

  • Wuchereria bancrofti

Mycoplasma

  • Mycoplasma pneumoniae

Protozoa

  • Blastocystis hominis

  • Entamoeba histolytica

  • Giardia lamblia

  • Plasmodium spp.

  • Trichomonas vaginalis

Rickettsia

  • Coxiella burnetii

Treponemes

  • Treponema pallidum

Viruses

  • Adenovirus a

  • Coxsackieviruses A9, A16, B4, B5 a

  • Cytomegalovirus

  • Echovirus 11 a

  • Epstein-Barr virus a

  • Hepatitis viruses A, B, C

  • Influenza B virus a

  • Human immunodeficiency virus

  • Measles virus, attenuated

  • Mumps virus

  • Parvovirus B19

  • Respiratory syncytial virus a

BOX 71.2
Noninfectious Causes and Associations of Urticaria and Urticarial Eruptions in Infants and Children

Arthropod Bites (Papular Urticaria)

  • Ants ( Solenopsis saevissima )

  • Bedbugs ( Cimex lectularius )

  • Bees a

    a Most common.

  • Body lice ( Pediculus humanus ) a

  • Caterpillars

  • Fleas ( Pulex irritans ) a

  • Chiggers ( Trombicula irritans )

  • Flies

  • Gypsy moths

  • Kissing bugs ( Triatoma sanguisuga )

  • Mosquitoes

  • Scabies mites ( Sarcoptes scabiei ) a

  • Scorpions

  • Spiders

  • Wasps

Annular Erythemas

  • Erythema multiforme

  • Annular erythema of infancy

  • Acute hemorrhagic edema of infancy

  • Erythema annulare centrifugum or gyrate erythema

Autoimmune or Contact

  • Animal dander

  • Caterpillars and moths (Lepidoptera)

  • Chemicals

  • Cosmetics

  • Epoxy resins

  • Fish

  • Coral

  • Jellyfish

  • Hedgehog

  • Foods

  • Medications

  • Nickel

  • Parabens

  • Saliva

  • Wood dust

Dermal Hypersensitivity Reactions

  • Eosinophilic cellulitis

  • Exanthematous drug eruptions

Drugs

  • Acetylsalicylic acid a , b

    b Can cause a pseudoallergic reaction.

  • Allopurinol

  • Amoxicillin a

  • Barbiturates

  • Cephalosporin antibiotics

  • Codeine

  • Curare

  • Meperidine

  • Morphine a

  • Nonsteroidal anti-inflammatory agents (e.g., indomethacin) a , b

  • Penicillin a

  • Phenytoin

  • Polymyxin B

  • Procainamide

  • Quinidine

  • Iodinated radiocontrast media b

  • Sulfa-derived antibiotics a

  • Sulfonylureas

  • Tetracycline

  • Thiamine

  • Thiazides

  • Vancomycin

  • Zidovudine

Food Additives, Preservatives, and Dyes (Pseudoallergic Reaction)

  • Azo dyes (e.g., sunset yellow, tartrazine a )

  • Butylhydroxyanisole

  • Butylhydroxytoluene

  • 4-Hydroxybenzoic acid a

  • Sodium benzoate a

  • Sodium metabisulfite

Food Allergy

  • Chocolate

  • Eggs a

  • Fish a

  • Fresh berries

  • Milk a

  • Nuts a

  • Peanuts a

  • Red meat (α-galactosidase)

  • Shellfish a

  • Tomatoes

Autoinflammatory Syndromes

  • Schnitzler syndrome

  • Cryopyrin-associated periodic syndromes (CAPSs)

  • Familial cold autoinflammatory syndrome

  • Neonatal-onset multisystem inflammatory disease (NOMID)

  • Muckle-Wells syndrome

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