SWELLING (ANGIOEDEMA)

Angioedema is an abrupt and short-lived swelling of the skin and/or tissues beneath the skin.  It can occur either alone or more commonly in combination with hives (urticaria), which are itchy welts of various sizes and shapes over the surface of the skin.

The swellings most commonly involve the eyelids and lips, less commonly the hands and feet, and rarely the linings inside the respiratory tract and digestive tract.  Itching is not a prominent feature as it is in hives, but the swellings can cause pain and/or tenderness.  They also can result in difficulty in breathing if they involve the tissues in the throat or abdominal pain/cramping if the intestines are affected.

COMMON CAUSES:

Acute Allergic Angioedema:  Usually accompanied by hives and occurs within 1 to 2 hours of exposure of an allergen.

1. Foods Allergies:  Nuts, Legumes (i.e., peanuts), Shellfish, Milk, Eggs, etc.
2. Drugs:  Penicillin, Sulfa, Aspirin, NSAID’s (non-steroidal anti-inflammatory drugs), Vaccines, etc.
3. Insect Venoms:  Honey Bees, Yellow Jackets, Hornets, Wasps, Fire Ants, etc.
4. Natural Rubber Latex:  Gloves, Catheters, Condoms, Dental dams, Balloons, etc.

Non-Allergic Drug reaction:  May occur days to months after beginning a medication.

1. ACE inhibitors:  Zestril (Lisinopril), Capoten (Captopril), Altace (ramipril), Vasotec (enalapril), Accupril (quinapril), Lotensin (benazepril), etc.
2. Angiotensin II Receptor Antagonists:  Cozaar (losartan), Diovan (valsartan), Avapro (irbesartan), Benicar (olmesartan), Atacand (candesartan), Micardis (telmisartan), etc.
3. Selective Serotonin Reuptake Inhibitors (SSRI’s):  Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), Lexapro (escitalopram), Luvox (fluvoxamine), etc.
4. Proton Pump Inhibitors:  Prilosec (omeprazole), Prevacid (lansoprazole), Nexium (esomeprazole), Protonix (pantoprazole), Aciphex (rabeprazole), Dexilant (dexlansoprazole), etc.
5. Statins:  Lipitor (atorvastatin), Zocor (simvastatin), Crestor (rosuvastatin), Pravachol (pravastatin), Mevacor (lovastatin), Lescol (fluvastatin), etc.

Hereditary Angioedema:  Inherited abnormal gene that causes deficiency of a normal blood protein called “C1 esterase inhibitor.”  It is manifested by repetitive swellings lasting for 1 to 2 days which usually begin in patients after puberty and are not accompanied by hives.  The episodes can be spontaneous or triggered by physical or emotional stress, alcohol, and/or hormonal factors.

Idiopathic:  No identifiable cause.  May be associated with autoimmune disorders like Systemic Lupus Erythematosus, Sjögren’s Syndrome, Rheumatoid Arthritis, etc.

MECHANISM:

Leakage of fluid through the walls of the small blood vessels causing soft tissue swelling.

DIAGNOSIS:

Allergy skin testing and/or bloodwork can identify allergic and non-allergic triggers.  When hereditary angioedema is suspected, blood tests are needed to check for levels and function of specific complement proteins.

TREATMENT:

Severe Angioedema:  If the respiratory tract is involved causing difficulty in breathing, emergency treatments like inserting a tube in the throat may be needed to keep the airway open.

Mild Acute Angioedema:

1. Epinephrine injection into a muscle
2. Oral or injected antihistamines
3. Oral or injected corticosteroids

Chronic Angioedema:

1. Non-sedating antihistamines [Zyrtec (cetirizine), Allegra (fexofenadine), etc.]
2. Sedating antihistamines [Benadryl (diphenhydramine), Chlor-Trimeton chlorpheniramine, etc.]
3. Oral corticosteroids (prednisone, methylprednisolone, etc.)

Hereditary Angioedema:

Hereditary Angioedema does not respond to epinephrine, antihistamines, or corticosteroids. Emergency treatment involves intravenous C1 inhibitor concentrate.  It can also be infused prophylactically about 1 hour before a surgical procedure to prevent swellings.  Newer medications like Firazyr (icatibant) and Kalbitor (ecallantide) are also used to treat this condition.

RECOMMENDATION:

If you are experiencing episodes of swelling (angioedema), with or without associated hives (urticarial), the board certified allergists at Black & Kletz Allergy have several decades of experience in diagnosing the cause of your swelling episodes, and more importantly have the expertise in stopping these episodes.  We have been serving the Washington, DC area and treating this condition for more than 50 years.  It is important for us to take a detailed history, perform an examination and any necessary skin and/or blood tests in order to identify the offending allergen or trigger that is causing your swelling episodes.  As mentioned above, angioedema can be life-threatening as it can cause difficulty breathing if it affects your throat or other part of your respiratory system.  Please contact us to make an appointment if you would like to be seen in one of our three convenient locations in the Washington, DC metropolitan area.