Urticaria is one of the oldest and commonest skin diseases which is known since antiquity. It has been called with different names in different ages and in different parts of world. Urticaria, referred as hives, are raised, well-circumscribed areas of the skin erythema and oedema involving the dermis and epidermis with itching.
Historical review
Probably the earliest description of the disease is found in “The Yellow Emperor’s Inner Classic”, Huang Di Nei Jing, which was written sometimes between 1000-200 years before Christ.1 In chapter 64 of Basic questions (Sin Wen). Urticaria is called “Feng Yin Zheng” which means wind-type concealed rash. This is still the Chinese word for Urticaria which was thought to be due to excess in lesser Yin which causes obstruction of fluid in the skin.
Hippocrates (460-377 BC) described it as knidosis, derived from a Greek word knido (nettle), characterized by elevated lesions with itching caused by nettles and mosquitoes.4 He also mentions that the weals can occur in patients with gastrointestinal disorders but often with mild itching. The same term was again introduced by Jean-Louis Alibert in Paris in his book on skin diseases published in 1833.2 Hebra used the term knidosis for the chronic type of nettle rash whereas in Andrew’s and Domonko’s textbook (1963) , used this term synonymously with Urticaria.
Plinius (32-79 AD) introduced the term Uredo, a Latin word which means burning. The term was used by Latin speaking doctors such as Carl von Linné for “red, evanescent itching eruptions”.
Urticatio, a Latin word derived from Urere (to burn), and scarlatina Urticaria have also been used.4 Use of the term ‘morbus porcinus’, which means pig’s disease, resulted from a translational error of the intended term ‘morbus pocellaneus,’ which referred to the white colour of the central wheal.5
Jalinus (Galen, 129-200 A.D.), in his book Heelatul Barra , has mentioned Sharaa as Nabatul Lai’l because it becomes severe at night.38
Rabban Tabri (810-895 A.D. ), in his book Firdausul Hikmat , described that itching occur in case of Sharaa at night while in case of Hasaf during daytime, he also mentioned an effective treatment of Sharaa in the form of tila.40
Zakaria Razi (850-923 A.D.), the author of Kitabul Mansoori, has made a mention of Sharaa, according to him there are two types of Sharaa, one caused by mixing of khalis safra in blood and other by mixing of namkeen balgham in blood, the former is more severe than the later.11Zakaria Razi mentioned different views of many former Unani physicians related to its aetiology, clinical presentation and management in his book Al Hawi fit-Tib.38
Hasan Al-Qamri (9th century A.D.) quoted in Ghina Muna that Sharaa is caused by bukharat-e-maddah-e-kaseerah that arise from blood , these vapours are produced by kasrat-e-dam (excess of blood) or as result of mixing of balgham-e-shor in blood. He also discussed treatment of Urticaria extensively. 41
Sabit Bin Qurrah (9th century A.D.) described two types of sharaa on the basis of size; Sharaa e Kibar and Sharaa e Sighar. According to him, it is caused by dam-e- safrawi har and baroodat wa ratoobat-e-maleh, he also mentioned its clinical presentation and management . 49
Ali Ibn Abbas Majoosi (930-999A.D.), in his book Kamil-us-Sana’a classified Urticaria in two types, first one is caused by blood mixed with safra, these rashes are red in colour and patient feel hararat (hotness) in his body, other is produced by mixing of balghame shor in raqeeq khoon, sometimes Sharaa occurs as result of mixing of dam, balgham and safra.42
Sheikh Ibn Sina (980-1037A.D.), the author of Al Qanoon fil Tib, the Canon of Medicine, described that Sharaa is a damwi disease usually but it may also be due to safrawi khoon or balgham-e-boraqi. Sheikh also mentioned detailed criteria for fasd in the management of Sharaa.43
Ahmad Al-Tabri (10th century A.D.), in his book Al-Moalejat-e-Buqratiya, discussed Sharaa comprehensively. He mentioned that Sharaa is caused by hot hareef khoon mixed with rutubate fasidah ghaleezah in small amount or by mixing with rutubat-e-raqeeqa fasidah that become irritatent due to malahat (salinity). Sometimes mixing of akhlat saudawia causes this condition 39
Ismail Jurjani (12th century A.D.), in Zakhira Khwarzam Shahi , an encyclopaedia of Unani medicine, described Sharaa in detail. He mentioned that vapours of khoon-e- merari and balghame boraqi that are expelled out suddenly outside the body, cause Urticaria. He also described two type of Urticaria on the basis of involved khilt; sharaa e damwi and sharaa e balghami. He also discussed the detailed management of these two types of urticaria.44
Ibn-e-Hubal Baghdadi (1121-1213A.D.), quoted in Kitabul Mukhtarat fit Tib that the ecrid matter causing Sharaa my be damwi, safrawi or balghami. 46
Akbar Arzani (17th century A.D. ), author of Tibbe Akbar, considered Sharaa as busoor e musattah of reddish colour, variable in size associated with itching. Sometimes a fluid oozes from urticarial lesions that is known as dalam in Persian language.45
Ajmal Khan (1868-1927 A.D.), in Haziq, observed that bad-hazmi (indigestion) is the main predisposing factor for Urticaria, he also described the clinical presentation and treatment of Urticaria. 48
Thomas More in his book “King Richard III” gives an excellent description of the condition without giving it a name.6 However, it is of interest since it is the first case of Urticaria reported to cause death. In 1480 before the coronation of King Richard, the lords wanted to please him by serving him a cup of strawberries. A few hours later he suddenly assembled the lords, opened his shirt and showed his chest which was covered with red elevated and itching spots. He accused one of the lords for trying to poison him and had him assassinated on the spot.
The term Urticaria dates back to the 18th century, when the stinging and burning was likened to the sting of a nettle (Urtica dioica)3. Zedler in his “Grosses vollständige Universallexikon” from 1734-1740 changed uredo to urticatio.7
The word Urticaria was first introduced in 1769 by William Cullen in his book “Synopsia Nosalogiae Methodica” 8. It also appeared in the first edition of Encyclopaedia Britannica (1771) written by a pseudonym “A society of Gentlemen in Scotland”. The term Urticaria was later accepted by Peter Frank in Vienna and other centres. Cullen was Professor of Medicine in Edinburgh and had started to classify the skin disorders as Linné had done for the plants. He was a Quaker as were several of the doctors from the University of Pennsylvania who came to visit him 9 Philadelphia is still called the Quaker City, and here the first medical school in North America was founded in 1765. The first professors were all trained in Edinburgh.
Robert Wilan from England was also a Quaker and could therefore not be allowed to study in Oxford or Cambridge. He started his medical education 1777 in Edinburgh and become influenced by the ideas of Cullen on classification of skin disorders. In 1783 Willan returned to London where he soon was appointed physician to a newly established Public Dispensary in Carey Street. Here he saw a lot of poor people and also visited their home. Willan was kind to his patients, a sincere and reserved man, a good teacher and had an intense dislike for alcohol which was a common cause of premature death among his patients. He was especially interested in skin disorders and perfected the classification of cutaneous diseases based on the morphology of the lesions. He had read a book by Josef Plenck on the subject published in 1776 but since it was a mixture of lesion type, location and aetiology, he did not cite it 10 Willan’s findings started order in the existing classification and were published in parts between 1798 and 1808.11 In 1801 he met Thomas Bateman who had just finished his medical studies in Edinburgh. He joined him in the dispensary. Bateman was very religious and fond of music. He said never waste a minute and his pen was always in his hand. Bateman grasped Willan’s approach to skin problems and soon become his trusted assistant, friend and finally successor. Willan was stricken by a heart problem at the height of his fame. In 1811 he retired and sailed for Madeira to get cured, but died there at the age of 55. His work was completed by Bateman in an influential masterwork “A Practical Synopsis of Cutaneous Diseases” published 1813 and translated into many languages 12 Here different types of Urticaria were described; 1.Urticaria febrilis, where the patient has fever and abdominal pain for some days before the skin lesions appear. This Urticaria usually last for a week. 2.Urticaria evanida where new lesions can continue to appear for many months or years and mainly with itching at night. It thus corresponds to chronic Urticaria. 3. Urticaria perstans where the single central weal remains for some days and feels hard. The initial reddening around the weal disappears early. The description corresponds to urticarial vasculitis. Bateman also described lichen urticatus or papular Urticaria in children, which he differentiated from the Urticaria.
However, not everyone accepted their system. One was Jean Louis Alibert who was the leading dermatologist in Paris at that time. As mentioned before, he preferred the Greek word knidosis for Urticaria and wanted a new classification since Willan’s study was based on outpatients without a follow-up of possible aetiology. Alibert was an excellent teacher and observer who attracted doctors from all over Europe to Hospital Saint-Louis. When the lecture room become too small, he lectured in the hospital garden under the trees. Alibert stood on a wooden platform and called up the patients by name of the disease.13,14 A book on skin diseases by Alibert was admired by King Ludvig XVIII and he was appointed the King’s personal physician, which meant an important social position. After the death of King Ludvig, King Charles X kept him as physician and he was rewarded by the title Baron. He therefore left his department for many years. Laurent Biett, his best pupil, took over. He visited Bateman in 1816 and reintroduced the Willan-Bateman method in Paris. When Baron Alibert returned to St Louis in 1829, he tried to introduce his construction of a tree with dermatosis on the branches, but failed since it was too complicated and useless35
Several physical Urticarias were early mentioned: Solar Urticaria was described by Borsch in 1799 but it was not until 1887 that Veiel showed that it was only solar rays and not heat from a stove or candle that was responsible 15,16 Factitial Urticaria was first documented in the middle-ages since people with this condition were beheaded or burnt alive because they were assumed to be related to the devil 17 In the medical literature it was described by Heberden in 1767 and Gull coined the name factitious Urticaria in 1859 18,19 Cold Urticaria was described by Frank in 1792 20 Urticaria caused by heat and mental or physical exertion was published in 1924 in JAMA by Duke 21 Pressure Urticaria was described by Urbach and Fasal in 1929 22. Aquagenic Urticaria was reported by Shelley and Rawnsley in 1964 and adrenergic Urticaria by Shelley & Shelley in 1985 23,24
Urticaria pigmentosa was described by Edward Nettleship early in this career (1869) before he specialized in ophthalmology 25 He called it chronic Urticaria leaving brown stains. Sangster named it Urticaria pigmentosa and Unna discovered the mast cells in the lesions26,27
Angio-oedema was described 1586 by Marcello Donati in a young count who was sensitive to egg 29 Hereditary angio-oedema was reported by Osler in 1885 29 It was a fatal case due to suffocation which was a common cause of death in the family. In Sweden the cause of death has been registered by the church. Therefore, Arnoldsson et al in 1966, could trace a family back to the 17th century 30 Donaldson and Evans in 1963 found that these patients could have low levels of the inhibitor to C1 esterase which caused the swelling 32
Heinrich Iraneus Quinke was a Professor in Kiel in 1878 where he remained for 30 years. He made significant contributions on various internal disorders and introduced lumbar puncture as a diagnostic and therapeutic aid. Quincke also introduced new apparatuses into medicine. One of his doctoral students Eugen Dinkellacker published a thesis in 1882 on acute oedema with 12 references to previous reports. Quincke wrote the same year a summary of it 32It appeared as an original report but had no references to the previous reports although he was well aware of their existence. To honour Quinke, Dr F Mendel in 1902 published a paper in Berliner Woshensschrift on circumscribed oedema and proposed the name Quinke oedema. Within the same year this name was used all over the world.33
Jean Astruc (1684-1766) founder of modern dermatology and histology, showed that the wheal occurs due to a local obstruction of oedema. The French author EJ Marey (1858) described the triple response but he did not mention where it had been published34 Imidizolethylamine was synthesized by Windaus and Vogt 35Dale and Laidlow showed that the tissue contained an amine which affected smooth muscles and vessels. They called it histamine 36The first antihistaminic compound was discovered by Bovet and Staub 37 Recent advances in diagnosis and treatment have been the use of the RAST, the corticosteroids and the non or less sedating antihistamines