Persons with autoimmune disorders, especially thyroid disorders, lupus and Sjogren's, are at risk for rashes, hives and urticarial vasculitis.
Rashes and hives, which are technically referred to as urticaria and angioedema, are common occurrences in people with allergies and autoimmune diseases. Urticaria is defined by rashes that are characterized by a raised swelling of the skin with itching that typically lasts no longer than 24-48 hours. Angioedema presents as a deeper, nondependent swelling without itching. In certain types of urticaria and angioedema, the underlying cause is autoimmunity related to the presence of thyroid antibodies or an acquired C1 inhibitor deficiency.
The cumulative lifetime incidence of urticaria is estimated to be as high as 20 percent in the general population. The most common cause is IgE mediated (allergic) reactions to food or drugs. The cause is mast cell degeneration with release of histamine caused by the formation of IgE antibodies. When the offending trigger is identified and removed the urticaria resolves.
When the solution isn’t as simple and urticaria persists for longer than 6 weeks, the condition is known as chronic urticaria. Approximately 50 percent of patients with chronic urticaria also have conditions of angioedema. When both conditions are present the condition is seldom related to allergy and it is known as chronic idiopathic urticaria/angioedema.
The Role of Thyroid Antibodies
Several groups of researchers have described a relationship between chronic urticaria and thyroid disease, primarily Hashimoto’s thyroiditis and to a lesser extent Graves’ disease. These patients typically have levels thyroid peroxidase antibodies. In general, these patients had severe chronic urticaria/angioedema and no other signs of thyroid disease although some patients had a slight goiter. Treatment with levothyroxine caused improvement in the urticaria and angioedema. When treatment was stopped the symptoms returned and then subsided with the continuation of treatment. In the patients without evidence of thyroid antibodies, levothyroxine had no effect. The pathogenic relationship between thyroid antibodies and the chronic urticaria hasn’t yet been determined.
Anti-FceRIα antibodies
Another group of patients with chronic urticaria were found to have autoantibodies to FceRIα. These patients reacted to serum from normal subjects with wheals and flares.
Urticarial Vasculitis
Chronic urticaria may also be associated with a leukocytoclastic (white blood cell-mediated) vasculitis confined to skin or to a wider area of connective tissue. Palpable purpura (small purplish bruises) and urticaria of long duration are typically seen in urticarial vasculitis. Urticarial vasculitis often occurs in systemic lupus, polymyositis, mixed cryoglobulinemia, and Sjogren’s disease and tends to be associated with low levels of C1q.
C1 Inhibitor Deficiency
Patients with C1 inhibitor deficiency often have recurrent attacks of angioedema. C1 inhibitor is a multifunctional serine protease inhibitor that inhibits the immune system’s complement system. Complement represents a number of immune system chemicals. In patients with autoimmune diseases, C1 inhibitor may be catalyzed at an accelerated rate, causing an acquired C1 inhibitor deficiency and resulting angioedema. These patients generally have anti-idiotypic autoantibodies, which are thought to activate complement and lead to the C1 inhibitor deficiency.
Resources:
Bruce Zaraw, Urticaria, Angioedema, and Autoimmunity, Progress and Controversies in Autoimmune Disease Testing, Clinics in Laboratory Medicine, Philadelphia: W.B. Saunders, 1997.
Dreyfus, DH, Steroid-resistant chronic urticaria associated with anti-thyroid microsomal (peroxidase) antibodies in a 9-year old boy, Journal of Pediatrics, 1996; 128.
The copyright of the article Rashes and Hives in Autoimmune Disease is owned by Elaine Moore. Permission to republish Rashes and Hives in print or online must be granted by the author in writing.
hello! I have had 2 -3 episodes of angioedema per year for the last 15
years (I am 60, female, post menopausal, have both celiac and sjogren's
diseases). Our rescue dog had to begin treatment for severe pulmonary
hypertension and damaged valves with a combination of an ace inhibitor
(Enalopril), a bronchodilator (Theophylline), and a vasodilator
(Pimobendan). When I began administering these meds, I had 6 episodes of
angioedema within 5 weeks (throat, tongue, feet, hands). I can only
presume that handling these drugs (or just the Enalopril) is as reactive as
ingesting them myself! Has anyone else observed a similar reaction? (I
now use gloves + a dust mask when giving our dog his meds.) Regards,
Susan
Feb 10, 2009 9:45 AM
Elaine Moore :
Hi, If the gloves take care of the problem it likely is the enalapril.
I had a similar reaction to anafranil. Best, Elaine
Mar 4, 2009 8:29 AM
Guest
:
Have had hives daily for 3 months now. thyroid antibodies are elevated and
was diagnosed with Hashimotos thyroiditis yesterday. But Dr. didn't want to
treat yet, saying eventually it would turn into hypothyroidism and he will
treat that. So for now, I guess I have to live with the hives.
Mar 4, 2009 8:30 AM
Guest
:
Have had hives daily for 3 months now. thyroid antibodies are elevated and
was diagnosed with Hashimotos thyroiditis yesterday. But Dr. didn't want to
treat yet, saying eventually it would turn into hypothyroidism and he will
treat that. So for now, I guess I have to live with the hives.
Mar 5, 2009 8:14 AM
Elaine Moore :
Hi, I'm surprised your doctor hasn't started treatment. When thyroid
antibodies are present, thyroid hormone is often started. Other treatments
used for hives include diphenhydramine (Benadryl), hydroxyzine (Atarax),
corticosteroids, vitamin A, and Zantac. I hope some of the topical
preparations bring your relief. Perhaps you can get a referral to see a
dermatologist. Best, Elaine
Mar 7, 2009 11:06 PM
Guest
:
I have had urticaria vasculitis for 12 years now.In the first few years
medications didnt seem to work.When I went unmedicated is when I started to
seperate side effects from symptoms.I react to a variety of
things(ice,sun,foods,medications,presure against my skin & most of all
stress)so to keep away from these things has been more benifical than
anything.There are times breakouts occure & meds are needed but you
must identify what your triggers are.I am now having problems with gut pain
& headaches & I cant seem to get my Dr. to see it could be the
Urtcaria Vasculitis.I have only been using benadril & ibuprophin for
years because I grow ammune to other meds so fast & I know there will
come a day they have to work to save my life.How do you explain to a Dr.
Urticaria Vasculitis?
Mar 9, 2009 10:18 AM
Elaine Moore :
Hi, You're doing a great job of keeping symptoms in line. Avoiding
triggers is so important. Over time, ibuprofen can cause gut pain. I
know some of the doctors at National Jewish are using a combination of
Zantac, Zyrtec and thyroid hormone (if thyroid antibodies are present). You might want to see if there's an immunologist in your area. Best,
Elaine
Mar 16, 2009 10:57 AM
Guest
:
For the guest - FIND ANOTHER DOCTOR. Thyroid hormone was the only thing
that helped my 12 year old duaghter with chronic hives, who had normal
thyroid function, but elevated anitbodies. Her thryroid eventually became
underactive, but we still needed periodic increases of thyroid hormone to
contol the hives. Thankfully, after 6 years of bouts of hives, she has
been hive-free for almost 6 years. We also saw doctors at National Jewish
who specialized in the immune system. Don't give up - hive is a "four
letter word" for sure!
Apr 7, 2009 9:20 AM
Guest
:
I've just been diagnosed with Hashimoto's thyroiditis after suffering with
hives and angioedema for two months. I first went to an allergist who
determined the cause was not a food allergy but elevated TPO sent me to an
endo. He has me on small doses of synthroid. I'm wondering if I continue
with the allergy medication (Zyzol, Zantac, hydroxyzine) and the hives
clear up, how will I know if the synthroid is what worked or the allergy
meds? I hate the idea of taking medication but don't like suffering either.
Any ideas are appreciated. ~Dee
Apr 7, 2009 9:28 AM
Elaine Moore :
Hi, Since you've been diagnosed with Hashimoto's thyroiditis, you
probably need to be on thyroid replacement hormone to keep your levels in
an optimal range. This will also slow your gland's activity down and help
reduce thyroid antibody production. The other meds will help inhibit the
allergic reaction.
Most people I know who have the same problem
as you are on thyroid hormone, zantac, and either zyrtec or claritin. Over
time, they've been able to reduce the antihistamine, using it only at night
or as needed.
You'll probably need to continue on the
replacement hormone, and as your symptoms abate discuss with your doctor
the possibility of cutting back on or stopping the other meds. Best,
Elaine
Apr 7, 2009 3:02 PM
Guest
:
I've just been diagnosed with Hashimoto's thyroiditis after suffering with
hives and angioedema for two months. I first went to an allergist who
determined the cause was not a food allergy but elevated TPO sent me to an
endo. He has me on small doses of synthroid. I'm wondering if I continue
with the allergy medication (Zyzol, Zantac, hydroxyzine) and the hives
clear up, how will I know if the synthroid is what worked or the allergy
meds? I hate the idea of taking medication but don't like suffering either.
Any ideas are appreciated. ~Dee
Apr 14, 2009 11:45 AM
Guest
:
Elaine, I have suffered from chronic hives since I was 16; I am now 29
and having outbreaks of hives again. I usually have an outbreak every 3 to
5 years. I was diagnosed with Hashimotos thyroiditis several years ago and
have been on levothyroxin since. My thyroid level was tested when this
recent outbreak occured and my levels are fine. My doctor has me on a
combination of Zyrtec and Doxpin, but the hives are still happening. Are
there any other medications that help hives? Should I see another
doctor?
Apr 14, 2009 12:24 PM
Elaine Moore :
Hi, Your thyroid hormone levels may well be within the normal range,
but they still may be too low for your body's needs, especially if your
doctor is measuring you with TSH alone. When FT4 and or/FT3 are too low,
the immune system produces more thyroid antibodies as it speeds up its
activities trying to fix the problem. This increased thyroid antibody
production is what seems to cause the hives. Most doctors who treat
this use zantac, zyrtec, hydroxyzine, or claritin, nasal steroids and
adequate thyroid hormone. I hope it's not doxepin your doctor is using.
This is an antidepressant and wouldn't be useful. It'd be good if you
could see an immunologist who's familiar with this or a good dermatologist.
Best, Elaine
Apr 14, 2009 10:18 PM
Guest
:
Hi, I have had cronic hives 4 months now recently had a blood test which
came up positive for autoimmune problem with all other functions normal.
For a while I was holding the hives at bay with a single antihistimine a
day now two of the same give no relief. The doctor claims it is likely to
go away eventually. Am I doing more harm by not medicating and just putting
up with the hives as long as I can or should I start taking heavier
meds?
Apr 15, 2009 5:13 AM
Elaine Moore :
Hi, It's probably more of a case of needing the right medications than
more medications. Often, hives are caused by reactions to foods and
medications or they can be due to an autoimmune thyroid condition, which
doesn't necessarily cause a thyroid disease. It would be good to see an
allergist or immunologist who can run the correct tests and determine the
best treatment. Take care, Elaine
May 22, 2009 8:57 AM
Elaine Moore :
Hi, I'm sorry to hear about your 4-week episode of urticaria. There's
a clear association between thyroid antibodies and urticaria, and thyroid
antibodies increase dramatically after RAI. You might also want to
read this article,
autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies
In general, patients are put on Zantac, antihistamines like
Zyrtec, and sufficient thyroid replacement hormone. After RAI, TSH levels
are usually falsely decreased so it's important to look at FT4 and FT3
levels. Having adequate thyroid hormone and avoiding environmental triggers
such as excess dietary iodine will help reduce your thyroid antibody
levels. Best, Elaine
Jun 3, 2009 3:11 PM
Elaine Moore :
Hi,
Because you mentioned your bottom, dermatitis herpetiformis
comes to mind. This is a condition that can occur in gluten sensitivity,
thyroid conditions and other autoimmune conditions. You may want to read my
articles on chronic urticaria in thyroid disease and dermatitis
herpetiformis and also this one on tpo antibodies: autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies<
br /> Let me know what you think. Best, Elaine
Jun 3, 2009 6:50 PM
Elaine Moore :
Hi, Your doctor may have tested you for thyroid function with TSH, FT4
and FT3 tests but he may not have tested you for thyroid antibodies. It's
important to have tests for TPO antibodies since they're associated with
both angioedema and miscarriages. see
autoimmunedisease.suite101.com/article.cfm/thyroid_peroxidase_antibodies
One of the most common causes of multiple miscarriages is
antiphosholipid syndrome See
autoimmunedisease.suite101.com/article.cfm/antiphospholipid_syndrome_ aps
This is also an autoimmune disorder in which antibodies cause the
blood to clot too soon. Although you mentioned one miscarriage, it might be
good to test for APS while having tests for TPO antibodies. Best, Elaine
Jun 4, 2009 10:04 AM
Guest
:
Guest: I am a thirty year old male. Some two and a half months back,
while I was sleeping, I felt a bit of itching sensation in my inner palms
and hands. At that time I concluded that it was an insect bite and did not
give it much importance. Then the itching grew more intense with every
passing night. One night I felt a bit of itching sensation on the rim of my
lower lip and when I scratched, after some time, one side of my lip got
swelled and till morning it had migrated to the other side of my lip. After
taking citrazine the condition faded away till midday. But after that, I
repeatedly used to get these swellings and red spot at different locations
of the body. The areas most affected include lips, hands, fingers, eyes.
Once or twice my private parts also got involved. I consulted a couple of
doctors who diagnosed me with chronic urticaria/angioedema and prescribed
levocitrazine. After taking the drug, i do get relief but once i
discontinue the drug the condition reoccurs. The condition is getting more
and more worse day by day. I also tried to identify the allergin but in
vain.
Jun 4, 2009 7:49 PM
Elaine Moore :
Hi, I could see where the citrizine meds would help if you had a
response to a bug bite. But angioedema and hives often start with itching
in the hands. It would be good to have tests for thyroid antibodies to see
if you might be having a thyroid antibody mediated response. Best, Elaine
Jun 12, 2009 12:25 PM
Guest
:
I was diagnosed w/ Hashimotos thyroiditis about 3 years ago & have had
hives for about 6 weeks, my endo. sent me to an allergist, she ran some
blood test but I haven't gotten the results yet. In the mean time she
perscribed Allegra but that doesn't help at all, the only thing that helps
is Benedryl but it makes me so sleepy, any suggestions?
Jun 13, 2009 7:54 PM
Elaine Moore :
Hi, I'm sorry to hear about your hives. Hives are often caused
by allergies to food and/or medications and they can occur when thyroid
hormone levels are low in people with TPO antibodies. These antibodies are
typically seen in Hashimoto's thyroiditis. If no allergies show up in your
tests you might want to ask about the role of thyroid antibodies. Best,
Elaine
Jun 30, 2009 5:31 PM
Elaine Moore :
Hi, Childbirth can cause some significant immune system changes. Women
occasionally develop thyroid antibodies, specifically TPO antibodies,
although they don't necessarily develop thyroid disorders. These antibodies
can be associated with rashes. Although you don't want skin tests, there
are blood tests such as RAST tests for allergens, and tests for TPO
antibodies that could help with your diagnosis. Congratulations on your new
baby! Best, Elaine
