Jake, is a 24 yo lawyer who came to you with a chief complaint of pruritic rashes in his back and

upper extremities. One day prior to consult, he noticed the rashes appeared around 30 minutes
after he completed a 10K marathon. This was associated with dizziness and headache. Patient
is known to be allergic to nuts and shellfish. Upon physical examination, heart rate, respiratory
rate and body temperature were normal. Inspection of the body revealed rashes that are
distinct, small and 1-2 mm wheals surrounded by large areas of erythema in his shoulders, back
and upper extremities. No noted swelling in the orbital area.

1. Based on these clinical findings, what is your primary impression?

Cholinergic Urticaria
Pertinent Positives:
● pruritic rashes in the back and upper extremities
● rashes appeared ~30 mins after completing a 10k marathon
● dizziness and headache
● history of nuts and shellfish (history of atopy)
● distinct, small and 1-2 mm wheals surrounded by large areas of erythema in his
shoulders, back and upper extremities
● no swelling in the orbital area
● normal heart rate, respiratory rate and body temperature

2. Give at least 2 differential diagnoses and support your claim.

Solar Urticaria
Pertinent Positives:
● pruritic rashes appearing 30 mins after running a marathon
● dizziness and headache
● history of nuts and shellfish (history of atopy)
● distinct, small and 1-2 mm wheals surrounded by large areas of erythema in his
shoulders, back and upper extremities
Pertinent Negatives:
 ● Rashes did not disappear after cessation of light exposure
● no swelling in the orbital area
● Rashes appearing in the back and upper extremities (in solar urticaria, rashes appear on
the exposed areas vs cholinergic urticaria where rashes appear in the covered areas)

Spontaneous Urticaria
Pertinent Positives:
● history of nuts and shellfish (history of atopy)
Pertinent Negatives:
● Persistent urticaria
● Size of rash
● Distribution in any area of the body
● Rashes appearing in the back and upper extremities

Exercise-induced Anaphylaxis
Pertinent Positives:
● pruritic rashes appearing 30 mins after running a marathon
● dizziness and headache
● history of nuts and shellfish (history of atopy)
Pertinent Negatives:
● no syncope or respiratory distress
● normal heart rate, respiratory rate and body temperature
● distinct, small and 1-2 mm wheals

3. How will you manage your patient?

● Supportive treatment: 2nd gen non-sedating oral antihistamines
● Low to moderate potency topical corticosteroids for a short duration
● cool shower, press a cloth soaked in cool water to your skin, or stand in front of a
fan
● Use hypoallergenic soap.
● Colloidal oatmeal bath to lessen pruritus and erythema once a day. Leave on
skin for 2-3 minutes then wash off with running water
● In the evening, use of specially-formulated emollients e.g. Physiogel AI (soothing
relief lotion) to lessen erythema and pruritus.