Papular Urticaria

Clinical Case

Case 1

  • 12-year-old female
  • No significant past medical history and she takes no medications
  • Review of systems is notable only for pruritus and occasional lack of sleep in association with the rash
  • Presents for management of pruritic papules on the legs and arms that started in the springtime and recur in crops
  • No other household members are affected
  • There is a cat living with the family

 Initial evaluation

  • Tired but otherwise well-appearing female
  • Firm erythematous papules with central punctum scattered in a symmetric eruption on arms and legs, few scattered on trunk without mucosal lesions
  • No linear burrows or other stigmata of scabies
  • No evidence of lice on the body or on clothing
  • Diagnosis: favor papular urticaria
  • There is no evidence of bacterial superinfection of the skin. A regimen of nonsedating antihistamines during the day (loratadine 10 mg twice daily) and sedating antihistamine (hydroxyzine 10 mg at bedtime) and topical corticosteroid cream (fluocinonide cream 0.05%) are prescribed. The family is counseled, advised to seek consultation with a veterinarian for evaluation of their pet cat and also a professional exterminator to determine whether the home is infested by fleas. Strategies for avoiding bites are discussed
  • Follow-up in 4 weeks

 Follow-up evaluation

  • The rash is much improved, however the family reports that the lesions are less frequent in number and less intense in symptoms
  • The family reports that the veterinarian and exterminator identified a flea infestation involving the pet cat and decontamination of the pet and household environment was ongoing.
  • Follow-up in 8 weeks (Resolved—few lesions only. The daytime nonsedating antihistamines are continued until full resolution of the recurrent lesions.)