Insights from a Dermatologist with Urticaria

In a recent interview with Dermatology Times, Jason Hawkes, MD, MS, a medical dermatologist and principal investigator at the Oregon Medical Research Center in Portland, Oregon, shared his unique personal and professional insights into urticaria, a condition that has shaped his journey in medicine. His experience with cold urticaria began during his second year of medical school, catalyzing his interest in this complex condition.

“My story started when I was a second-year medical student,” Hawkes recounts. “I started getting hives and wheels and itching following cold exposures. At the time, I didn't really make the connection, but found that particularly when I would go through the cold and come back into a warm environment such as the hospital or the clinic, I started breaking out in red splotches and some wheels that started to form.”

Over 15 years later, Hawkes continues to manage his chronic cold urticaria while advancing the understanding of urticaria as a clinician and researcher. His firsthand experience has fueled his passion for helping others navigate this condition.

Understanding Urticaria

Urticaria, commonly known as hives, is a skin condition characterized by itchy, raised welts or wheels. These can be triggered by various factors, ranging from allergens to environmental stimuli. Hawkes highlights the distinction between chronic inducible urticaria (CIU), such as cold urticaria, and chronic spontaneous urticaria (CSU), which lacks identifiable triggers.

“About 20% of chronic urticaria cases are inducible,” he explains. “They have very different trajectories, one being caused by a specific stimulus. In my case, cold urticaria, as opposed to the chronic spontaneous urticaria patients or CSU, who don't have any particular stimuli.”

Diagnosis and Testing

A key aspect of managing urticaria involves accurate diagnosis. Provocation testing plays a significant role in identifying CIU triggers. For cold urticaria, this often includes the ice cube test, a simple yet effective diagnostic tool.

“We can put an ice cube on the inner forearm, let it sit for about 5 minutes or so, and then wait 10 or 15 minutes to see if a wheel forms in those sites,” Hawkes shares. However, he notes that such tests are not foolproof: “In my case, with cold urticaria, I actually failed the ice cube test, but I had a very consistent exposure and symptom correlation with cold.”

Hawkes emphasizes the importance of detailed patient histories and clinical interaction to uncover predominant triggers. “It doesn't mean that [patients will] always have symptoms that are perfectly correlated, but it should be their predominant factor.”

Complexity of Symptoms 

One of the challenges in managing urticaria lies in the coexistence of multiple urticaria types in a single patient. Hawkes points out that individuals with CSU may also exhibit features of CIU, such as pressure urticaria or dermatographism.

“Patients often have a mix of the different types of cold urticaria or chronic urticaria,” he explains. “For example, they can have a primary CSU but have components such as pressure or dermatographism, and may also have other aspects, like cholinergic urticaria.”

Implications for Treatment 

The variable nature of urticaria underscores the need for individualized care plans tailored to each patient's triggers and symptoms. Hawkes’ dual perspective as both a patient and a dermatologist highlights the importance of understanding the nuances of the condition to optimize treatment outcomes.

“I hope this is helpful,” Hawkes concludes, reflecting on the need for ongoing dialogue and research to support patients with urticaria. His story serves as a valuable resource for both clinicians and individuals living with this condition, offering insights into the challenges and strategies for managing chronic urticaria effectively.