What is the treatment for dermatographism?

Management of Dermatographism

First-line treatment for dermatographism is non-sedating H1 antihistamines, which may need to be increased up to 4 times the standard dose for adequate symptom control. 1

Understanding Dermatographism

Dermatographism (also called "skin writing") is the most common type of physical urticaria, affecting approximately 2-5% of the general population. It manifests as linear wheals that develop after scratching or friction on the skin, often accompanied by itching and burning sensations. For many patients, even light pressure or rubbing from clothing can trigger widespread wheal-and-flare reactions 2, 3.

Treatment Algorithm

First-line Treatment:

• Non-sedating H1 antihistamines:
  • Start with standard doses of medications such as fexofenadine 180mg daily 4
  • For patients with inadequate response, increase the dose up to 4 times the standard dose 1
  • Options include:
    • Fexofenadine 180mg (can be increased if needed)
    • Cetirizine
    • Loratadine
    • Desloratadine
    • Levocetirizine

Second-line Treatment (for antihistamine-resistant cases):

• Narrowband UVB phototherapy:
  • Administered 3 times weekly for 6 weeks
  • Starting at 50% of minimal erythema dose with 20% increments as tolerated
  • Has shown significant improvement in both itching (52.3% reduction) and whealing (71% reduction) 5, 6

Adjunctive Measures:

• Trigger avoidance:

  • Minimize skin trauma and friction
  • Avoid tight clothing
  • Use soap-free shower gels and bath oils 7
  • Apply urea- or glycerin-based moisturizers to maintain skin hydration 7
  • Avoid excessive heat or cold exposure

• For acute flares:

  • Topical polidocanol cream for symptomatic relief 7
  • Consider topical steroids for inflammatory lesions 7

Clinical Pearls and Caveats

1. Effectiveness of antihistamines: About 49% of patients report marked improvement with antihistamines, while 23% become symptom-free 3. Continuous rather than as-needed use is more effective.

2. Symptom patterns: Most patients experience continuous symptoms, but approximately 25% may have prolonged symptom-free phases 3. Symptoms are typically worse in the evening (81% of patients).

3. Associated factors: Consider evaluating for potential triggers or associated conditions:

   • Psychological stress (reported in 30% of patients) 2
   • Atopy (found in 12.5% of patients) 2
   • Drug reactions
   • Thyroid disorders

4. Quality of life impact: Dermatographism significantly impairs quality of life in 44% of patients, with 7% reporting they cannot lead a normal life 3. Address this aspect of care through proper education and treatment.

5. Treatment duration: The effects of narrowband UVB phototherapy may last 12-18 weeks after completion of treatment, after which symptoms may gradually return 5.

For patients with severe, antihistamine-resistant dermatographism that significantly impacts quality of life, referral to a dermatologist or allergist with experience in physical urticarias is recommended for consideration of advanced therapies.