Wir überwinden Grenzen

(20.07.2016) Peter Fischer* has been suffering from very painful swellings the size of the palm of his hand for a year now. They mainly occur on his thighs, forearms and buttocks and are so itchy that Fischer constantly wants to scratch them. Occasionally, small blisters even form on the swellings. Fischer had already seen various doctors before he came to the outpatient clinic of the Department of Dermatology and Venereology at the Freiburg University Medical Center.

The swellings are now so painful that Fischer can no longer even sit for long periods of time and has been on sick leave from his office job for several months. The man, who is in his late 50s, is even being considered for early retirement, which is an additional burden for him. Antibiotic treatment for a possible bacterial infection has been unsuccessful. From time to time, wheals form on Fischer's skin that look similar to mosquito bites. They made the doctors sit up and take notice. Could there be a connection between the extensive swelling and the localized skin elevations?

The doctors refer the patient to the dermatology clinic's outpatient allergy department. "The wheals are a typical sign of urticaria, also known as hives," says Dr. Sabine Müller, senior physician at the Department of Dermatology and Venereology at the Freiburg University Medical Center. "But the blisters didn't really fit the picture."

Hives are one of the most common skin diseases. Around one in four people suffer from it at least once in their lives. However, finding the causes - and therefore the causal treatment - is difficult. The symptoms often include skin rashes, wheals and itching. The causes are also very varied. Intolerances to food additives, bacterial or viral infections, but also physical stimuli such as pressure, cold and light can cause the symptoms. All of this leads to mast cells in the skin releasing their messenger substance histamine. This leads to itching, dilates the blood vessels and causes swelling and redness in the skin.

Peter Fischer's doctors pricked up their ears when the patient told them that the swelling was particularly bad when he had been sitting at his desk for a long time. In other words, the swelling appears where pressure has been exerted on the skin. To test this, a ten-kilogram weight is hung over Fischer's shoulder on a strap for ten minutes. Dr. Müller then takes it off and checks the skin for several hours. Nothing happens for a long time. "It wasn't until six hours after the strain that a swelling developed that looked exactly like the swelling on her arms, legs and bottom," says Dr. Müller. This makes it clear that it is a case of delayed pressure-dependent hives. "The blisters are obviously the result of pronounced swelling in extremely severe hives," says Dr. Müller.

The usual treatment for pressure urticaria is started immediately, but without much success. At the same time, his spontaneous hives, the wheals, become more severe. But this is a stroke of luck for Peter Fischer. This is because doctors are allowed to use an antibody therapy against this form, which is not approved for pressure urticaria. The antibodies prevent the mast cells from being activated too strongly and thus causing the hives.

The patient is completely symptom-free after just one week. From then on, the antibodies must be injected under the skin every four weeks. As soon as this is no longer done, the disease returns. But Peter Fischer can live very well with this restriction. He has now returned to his job and has taken several long-distance trips. His illness can no longer stop him.

* Name changed by the editors