Chronic Water-Induced Skin Reactions: A Case of Suspected Aquagenic Urticaria

Case at a Glance

A 28-year-old female patient presents with an 18-year history of water-induced cutaneous reactions, characterized by urticarial lesions following water exposure, with severe exacerbation in marine environments.

Patient's Story

The patient, a French woman with a BMI of 30.5 kg/m² and a smoking history, reports the onset of skin reactions around age 10, with progressive worsening over time. She describes the development of pruritic erythematous rashes on the flexural areas of arms and legs, inner thighs, and popliteal fossae within minutes of water exposure during bathing or excessive perspiration. While freshwater-induced lesions resolve spontaneously within 20 minutes after drying, exposure to saline environments causes severe, persistent reactions that only subside when removed from coastal areas. The patient reports that even proximity to marine environments while fully clothed triggers debilitating symptoms, significantly impacting mobility due to severe involvement of knee and elbow flexures.

Initial Assessment

Multiple dermatological consultations over the years yielded no definitive diagnosis or effective treatment. The patient has independently researched her condition and suspects aquagenic urticaria, though previous physicians were unfamiliar with this diagnosis. Current management involves prophylactic application of occlusive barriers (petroleum jelly, Aquaphor) with limited efficacy.

The Diagnostic Journey

The patient's symptom pattern strongly suggests inducible urticaria, specifically aquagenic urticaria with possible additional triggers. The temporal relationship between water exposure and symptom onset, characteristic distribution pattern, and the marked exacerbation in saline environments support this diagnosis. The lack of recognition by multiple dermatologists highlights the underdiagnosis of rare urticaria subtypes.

Final Diagnosis

Aquagenic urticaria with possible concurrent cholinergic urticaria and enhanced sensitivity to osmotic or chemical triggers in marine environments.

Treatment Plan

Implementation of evidence-based treatment protocol for inducible urticaria, including second-generation H1-antihistamines as first-line therapy, with potential escalation to higher doses or combination therapy. Consideration of additional treatments such as H2-antihistamines, leukotriene receptor antagonists, or immunosuppressive agents if standard therapy proves insufficient. Patient education regarding trigger avoidance and emergency management.

Outcome and Follow-up

Patient provided with current evidence-based treatment guidelines for inducible urticaria. Recommended follow-up with dermatologist familiar with urticaria management for implementation of systematic treatment approach. Long-term monitoring for treatment response and quality of life improvement indicated.