|Year : 2006 | Volume
| Issue : 1 | Page : 36-39
Oral manifestations of dermographism
S Sunil1, P Deepak2
1 Dept. of Periodontics, KLE Dental College, Bangalore, India
2 Dept. Of Periodontics, JSS Dental College and Hospital, Mysore, India
Dept. of Periodontics, KLE Dental College, Yeswanthpur Suburb, Bangalore - 22 Kamataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dermographism is a type of physical urticaria, which literally means writing on skin. Dermographism may be defined as 'the appearance of a linear wheal at the site of brisk stroke with a firm object or by any configuration appropriate to the eliciting event'. In approximately 5 % of the population, exaggerated response of this constitutional whealing to trivial pressure and shearing forces is seen and termed dermographism. Although bronchial and genital mucosal involvement has been reported in the literature, there are no such instances where oral tissues were reported to be sensitive. This article reports one such unusual case, where a patient with dermographism also showed highly sensitive oral tissues. The increased sensitivity of oral tissues can lead to improper practice of oral hygiene habits, which can be crucial to oral health. Another rare finding was that this patient along with dermographism also had pressure urticaria, which by itself is quite rare. This article emphasizes importance of a detailed medical history, which could provide vital clues to the oral findings and help in management, when such patients are encountered.
Keywords: Dermographism, physical urticaria, linear wheal
|How to cite this article:|
Sunil S, Deepak P. Oral manifestations of dermographism. J Oral Maxillofac Pathol 2006;10:36-9
| Introduction|| |
Dermographism maybe defined as 'appearance of a linear wheal at the site of brisk stroke with a firm object or by any configuration appropriate to the eliciting event'. Dermographism is a physical urticaria, which literally means writing on skin. In 25-50% of people, firm stroking of the skin produces an initial red line (capillary dilatation); followed by an axon reflex flare with broadening erythema (arteriolar dilatation) and the formation of a linear wheal (transudation of fluid) termed the triple response of Lewis. In approximately 5 % of the population exaggerated response of this constitutional whealing to trivial pressure and shearing forces is seen and termed dermographism .
The exact mechanism of dermographism remains controversial. Trauma might release an antigen that interferes with the membrane-bound immunoglobulin E of mast cells, which releases inflammatory mediators, particularly histamine, into the tissues. This causes small blood vessels to leak, allowing fluid to accumulate in the skin. Other mediators involved are leukotrienes, heparin, bradykinin, kallikrein, and peptides such as substance P.
Dermographism is the most common physical urticaria and can occur with any other form of urticaria.
Approximately 4-5% of the population has dermographism. Incidence is increased in pregnancy (especially in second half) and at the onset of menopause. Most people with dermographism are otherwise healthy and no sex or racial variance is seen. Dermographism can appear at any age but is more common in young adults. Peak incidence is in the second and third decades.
Whealing usually develops within 5 minutes of stroking the skin and persists for 15-30 minutes. A refractory period after the wheal has cleared has been reported and often is short. Symptoms can be aggravated by heat (hot bath), minor pressure (scratching, friction from clothes, and rubbing with towels), exercise, stress, and emotion. Itching and whealing affect all body surfaces; however, the scalp and genitalia are involved less frequently. Although reports of association of genital and bronchial mucosa (2) are seen in the literature, there are no reports of oral cavity being affected .
Dermographism is usually idiopathic but may have an immunologic basis in some patients. Reports of passive transfer of dermatologic response with immunoglobulin E containing serum exist. Occasionally, dermographism may be triggered by an allergy to an external agent, such as penicillin, insect bites, scabies, or a worm infestation such as Fasciola hepatica. No association is seen with systemic diseases, food allergies, or medications (aspirin) nor does the incidence of atopy increase. In hyper eosinophilic syndrome, which has multi-systemic involvement and high mortality, approximately 75% have dermographism. Also it has been seen to follow a familial tendency with autosomal dominant pattern .
Hematological and biochemical screening tests in dermographism are usually normal.
Diagnosis is based on clinical examination alone and does not require histopathologic or biochemical assistance. The clinical observation includes checking the response after using moderate pressure to stroke or gently scratch the skin. The site is important, since areas protected from regular pressure and environmental influences, such as the back, are more reactive than buttocks and limbs.
Dermographometer can be a useful instrument to apply graded pressure (eg: 3600 g/cm) and record the skin responses.
Microscopically, features of non-specific inflammation with dermal edema and a few peri-vascular mononuclear cells are seen.
Management consists of recognition of the problem avoidance of the precipitating physical stimuli reduction of stress and anxiety and symptomatic treatment.
H1 + H2 antihistamine combination therapy has been shown to be more effective. Physical urticaria usually are unresponsive to corticosteroids. UV -B therapy and oral psoralen + UV -A therapy has been tried; but not of much benefit.
This article reports a patient with dermographism who was seen having exaggerated and peculiarly increased sensitivity of oral tissues to minor pressure.
A search through pertinent literature and discussions with dermatologists and dentists who might be familiar with cases of dermographism and related oral symptoms (if any) was not rewarding. None reported oral lesions in such cases and no review over this topic, makes a mention of exaggerated response or increased sensitivity of oral mucosa.
| Case report|| |
A 47-year-old male patient visited JSS Dental College and Hospital a year back with a complaint of bleeding of gums either spontaneously or on slight provocation since 7 to 8 years.
History revealed that bleeding occurred on brushing or while eating. Bleeding subsided after sometime without any medication or intervention. Bleeding episodes were recurrent in nature occurring on trivial stimulation. No history of other associated symptoms or any surface changes were noticed by the patient.
Past medical history revealed allergic rhinitis since childhood; Occurrence of swelling of palms on lifting weight and of feet on walking barefoot, which was attributed to pressure urticaria as a 12 year old boy; exaggerated 'Triple response of Lewis' since 7-8 yrs and has been diagnosed to have dermographism (has been under constant supervision of a dermatologist since then); was on corticosteroids, but discontinued the therapy due to development of adverse effects.
The patient was allergic to penicillin, sulpha drugs, ibuprofen, iodine mouth washes, chlorhexidine, and normal saline.
The patient had visited JSS Dental College and Hospital with the same problem 7-8 years back. He had undergone scaling for the first time, when he noticed that he had developed swelling of gums after scaling and the procedure also had triggered his rhinitis. Later the patient had consulted several dentists, however could not find much benefit. He had noticed that every time he gets the scaling done, he used to develop swelling of gums and rhinitis. A year back patient had revisited JSS Dental College and Hospital with the same problem and he was reviewed again.
General examination of skin revealed no pathologic surface changes, but on mild stroking with a firm (blunt) object, patient developed linear wheals along the line of stroke being made ('Triple response of Lewis') [Figure - 1]
Intraoral examination revealed moderate amounts of plaque and calculus. Gingiva was reddish pink with physiologic melanin pigmentation. It was edematous, shiny, and appeared soft.
This patient of dermographism showed concomitant existence of certain oral symptoms characterized by exaggerated response to trivial or minor degree of trauma like
- The touch of the probe or scalar tip caused development of highly erythematous areas, which used to persist for few hours and subsided gradually and uneventfully
- The accidental touch with a cheek retractor, while applying it caused a bruise over the lips and after application of the cheek retractor for a few minutes, the patient developed swelling of the lip and cheek areas [Figure - 2]
- The root planning procedure caused development of non-specific inflammatory swelling [Figure - 3]
Lab investigations revealed marginally elevated ESR, and increased AEC. Radiographic examination revealed moderate bone loss. (The site of blood withdrawal showed persistent swelling for a few hours).
The condition was provisional by diagnosed as increased sensitivity of oral tissues associated with dermographism and/ or pressure urticaria.
| Differential Diagnosis|| |
A differential diagnosis of desquamative gingivitis, oral pemphigus, and bullous lichen planus were considered.
A careful supragingival scaling was carried out without touching the gingiva as an initial treatment procedure.
Patient was recalled after a week for checkup and the gingiva appeared better than before scaling. The patient reported dull pain in right upper canine and first premolar region. These areas were detected to have moderately deep pockets and thus a root planing procedure was carried out in spite of encountering the development of erythematous areas. The patient reported after 2 days of root planing with development of an abscess in the canine-premolar region. He was prescribed antibiotics, H1 and H2 antihistamines, but the patient did not return for further treatment.
| Discussion|| |
Oral examination revealed highly sensitive oral tissues. This had adversely affected his oral hygiene procedures. While managing such patients, it is important to reduce the oral symptoms so as to enable the patient to carry out routine oral care. Blood investigations did not reveal any significant findings. However, the literature has revealed some important findings which might be found in such patients.
They are as follows:
- Significant reduction in the level of circulating alpha 1 antitrypsin, a protease inhibitor.
- Increase in blood histamine levels is seen after experimental scratching .
- Minimal involvement of eosinophils and neutrophils in dermographism .
- Significant rise in serum IgE levels .
After diagnosing the condition as dermographism in his last visit a year back, necessary treatment was done. But the patient could not keep up to his appointments in spite of repeated reminders.
However, the patient re- visited our department recently with the same complaint of bleeding gums, but this time reported that he had noticed reduction in the sensitivity of oral tissues, while brushing or eating. On examination, the oral tissues revealed to be normal to touch and probing procedures and thus scaling was carried out without encountering any problems. Also his skin reactions had reduced in intensity (i.e. after gentle scratching the wheal reaction was less intense and disappeared within 15 minutes, which used to persist for more than an hour previously). This reduction might be due to the self remitting nature of dermographism. It is important to record a detailed drug history in these cases as these patients are reported to be allergic to commonly used drugs in dentistry like mouth washes, local anesthesia, analgesics, saline (6) and the like. The self-remitting nature of this disorder may make it difficult to see dermal or oral symptoms in every case of dermographism; still a carefully recorded history sees that the clinician takes a watchful step when such a patient is encountered as these patients show allergy to multiple agents independent of the presence of dermographism. It is also seen that dermographism is common in patients with Behcet's disease. The prevalence of allergic responses is reportedly increased in Behcet's disease also , which asks for extra care that has to be exercised when treating these patients. Two other patients with dermographism were examined and were seen to be allergic to multiple drugs, but revealed no oral symptoms. This might be due to the self-remitting nature of the disease. There are also chances that the patient would have had some oral symptoms at some point of time, which might have gone unnoticed either due to ignorance about the condition or because of negligence. The association of dermal and oral findings and a possible link between the two in the present case might be a rare co-incidence, which has to be ruled out in the future. The patient along with dermographism also had pressure urticaria, which again is quite a rare finding and the association between pressure urticaria and oral findings also needs to be explored in the future.
| Conclusions|| |
Recognition of this benign disorder and reassurance is important in handling the condition. Treat dermographism symptomatically until the problem is adequately controlled or resolved. Careful attention has to be paid while managing these patients due to increased prevalence of allergic responses that are seen and due to increased sensitivity of oral and dermal tissues.
The natural history of symptomatic dermographism and the peculiarly increased sensitivity of oral tissues remain unclear. In many patients, the condition clears within 1-2 years, however in some may follow a protracted course. Further studies are required to reveal the cause of this condition and also identify probable association with the oral cavity.
| Acknowledgements|| |
I would like to thank Dr. Lekha Jagadish, MDS, Asso. Prof., Dept of Periodontics, JSS Dental College, Mysore, for her constant support, encouragement and assistance in reading the manuscripts. I would also like to thank Dr. Sheshadri, my colleague for his valuable help in preparation of manuscripts.
| References|| |
|1.||Laube S. (2004): Dermatographism. Website: See http://www.emedicine.com. dated 5th Oct 2004. |
|2.||Henz BM, Jeep S, Ziegert FS, Niemann J, Kunkel G. (1996): Dermal and bronchial hyperreactivity in urticarial dermographism and urticaria factitia. Allergy 51(3):171-175. |
|3.||Jedele KB. and Michels VV (1991): Familial dermographism. Am J Med Genet 39(2):201-3. |
|4.||McEvoy MT (1995): Immunohistological comparison of granulated cell proteins in induced immediate urticarial dermographism and delayed pressure urticaria lesions. Br J Dermatol 133(6): 853-60. |
|5.||Wang Z (1992): Clinical and histopathological observation and determination of serum IgE levels in patients with dermographism. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 14(6):437-40. |
|6.||Shall L, Saihan EM. (1992): Aberrant cutaneous wheal and flare responses in chronic urticaria. Acta Derm Venereol 72(6):451-3. |
|7.||Dinc A, et al. (2000): Dermographism and atopy in patients with Behcet's disease. : J Investig Allergol Clin Immunol 10(6):368-71. |
[Figure - 1], [Figure - 2], [Figure - 3]