Treatment of exercise-induced urticaria and anaphylaxis

Treatment of exercise-induced urticaria and anaphylaxis – Tips from Other Journals

Richard Sadovsky

As more people have begun participating in physical activity, exercise-induced urticaria and anaphylaxis have become more common. Symptoms of these syndromes range from mild urticaria with warmth and flushing to life-threatening laryngeal edema and vascular collapse. The presence of increased histamine levels in both syndromes hint that they are a continuum in a spectrum of entities. These syndromes are distinct from exercise-induced asthma in which skin symptoms do not occur. Because of the potential seriousness of these syndromes and the resultant limitation of activity, exercise-induced anaphylaxis and urticaria must be recognized and treated. Volcheck and Li review the symptoms, diagnosis and treatment of these exercise-induced syndromes.

There are three major types of exercise-induced urticaria and anaphylaxis: cholinergic urticaria, classic exercise-induced anaphylaxis, and variant type of exercise-induced anaphylaxis (see the accompanying table). Cholinergic urticaria typically occurs in patients between the ages of 10 and 30 years and presents as generalized flushing and distinctive, punctate 2- to 4-mm pruritic wheels surrounded by a red flare. This reaction occurs in response to an increase in core body temperature. Cholinergic urticaria is rarely associated with vascular collapse although, in severe cases, angioedema, bronchospasm and hypo tens ion can occur. Skin symptoms begin minutes after onset of exercise, peak within 30 minutes and resolve in two to four hours.

Classification of Exercise-Induced Syndromes

Type Precipitating event

Cholinergic urticaria Heat, stress, exercise

Exercise-induced Exercise only


Food-dependent Food in combination

exercise-induced with exercise


Variant Exercise only



Exercise-induced Exercise only


Type Urticarial morphology Vascular


Cholinergic urticaria Punctate (2 to 4 mm)


Exercise-induced Conventional

anaphylaxis (10 to 15 mm) Yes

Food-dependent Conventional Yes

exercise-induced (10 to 15 mm)


Variant Punctate (2 to 4 mm) Yes



Exercise-induced None No


Type Pulmonary


Cholinergic urticaria



anaphylaxis Laryngeal edema

Food-dependent Laryngeal edema



Variant Laryngeal edema



Exercise-induced Bronchospasm


Reprinted with permission from Volcheck GW, Li JT. Exercise-induced urticaria and anaphylaxis. Mayo Clin Proc 1997;72. 140-7.

Exercise-induced anaphylaxis usually manifests as fatigue, generalized warmth, pruritus and erythema with exercise progressing to an angioedematous urticarial eruption. Collapse with brief loss of consciousness can occur. Resolution of symptoms usually occurs within four hours, but later sequelae, including headaches, can persist for up to 72 hours.

Variant type of exercise-induced anaphylaxis is characterized by punctate urticaria (2 to 4 mm) that may progress to vascular collapse. In addition to these three categories, overlap syndromes with some features of each syndrome have been described.

These syndromes can usually be diagnosed by history. If the clinical picture is unclear, exercise challenge testing can reproduce the symptoms in a controlled atmosphere. Other major diagnostic considerations include idiopathic anaphylaxis and mastocytosis.

Treatment of an acute attack of exercise-induced anaphylaxis includes subcutaneously administered epinephrine, intravenously administered fluids, oxygen, antihistamines and airway maintenance. Prevention is difficult. If a precipitating factor such as food or medication can be identified, elimination of these factors six hours before exercise is the best preventive measure. For patients with skin symptoms only, hydroxyzine in dosages as high as 100 to 200 mg per day in divided doses may be helpful. For patients with systemic symptoms, histamine [H.sub.1] antagonists or combination antihistamine regimens such as hydroxyzine and cyproheptadine hydrochloride, 8 to 16 mg per day, may be helpful.

The author emphasizes that the main aspect of management is modification of each patient’s exercise program and education about avoiding exercise on warm or humid days and stopping exercise with the first evidence of symptoms. All patients should carry a self-injectable epinephrine kit and should be instructed in its use. Exercise should be done optimally with a partner who is aware of the patient’s condition and is capable of providing emergency assistance.

RICHARD SADOVSKY, M.D. Volcheck GW, Li JT. Exercise-induced urticaria and anaphylaxis. Mayo Clin Proc 1997;72:140-7.

COPYRIGHT 1997 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group