- What is Dermatographism?
- Causes of Dermatographism
- Pathophysiology of Dermatographism
- Manifestations of Dermatographism
- Types of Dermatographism
- Immediate Symptomatic Dermatographism (Factitious Urticaria)
- Follicular Dermatographism
- Delayed Dermatographism
- Cholinergic Dermatographism
- Red Dermatographism
- Cold Precipitated Dermographism
- Eliciting and Diagnosing Dermatographism
- Dermatographism Treatment and Remedies
- Myths on Dermatographism: Questions Answered
About four to five percent of the world’s population experience dermatographism. This condition is usually described as an exaggerated tendency of a person to wheal when there is stroking of the skin.
This is in contrast to the physiologic red flare appearing in the surrounding area of the skin after a skin rub, following formation of a white and red line, and slight swelling, which occurs in almost 25 to 50% of normal people. [1, 2, 3]
What is Dermatographism?
The word dermatographism is derived from the Greek terms translated as skin writing. Simply put, it is a disorder of the skin characterized as the skin becoming elevated and inflamed, resembling a hive. When the skin is rubbed or stroked with a dull, blunt object, it becomes raised and inflamed, assuming the shape and form of the stroke, and with a surrounding flare reaction. [4, 5]
Dermatographism literally means skin writing.
Causes of Dermatographism
The exact etiology of dermatographism is still unknown. However, it has been considered as a chronic type of physical urticaria, usually triggered by pressure, touch, and scratching. 
This condition has also been linked to chronic urticaria, both drug-induced and of idiopathic origin, to endocrinopathies like thyroid abnormalities and diabetes mellitus, to H. Pylori associated reactive polyarthritis, to hypereosinophilic syndrome, and even to an autosomal dominant inheritance. [1, 2, 7, 8, 9, 10]
A diagram showing the etiologic agents leading to dermatographism.
Pathophysiology of Dermatographism
An exaggeration of the triple response of Lewis is postulated to make up the pathologic processes of dermatographism.
The response is started with a capillary dilatation causing an appearance of an initially red line, after the stroking stimulus. An axon-reflex flare along with edematous extension follows, which is characteristic of arteriolar dilatation. Transudation of fluid and edema would eventually lead to a linear wheal formation, which the last phase among these responses. [2, 11]
The precise mechanism of dermatographism still is uncertain, but based on recent studies, it may be due to the mechanico-immunological triggering of mast cells. Trauma, or even a simple skin stroke, may release an antigen, interacting with immunoglobulin E of mast cells. Eventually, inflammatory mediators like histamines, heparin, kallikrein, bradykinins, peptides, and leukotrienes are released into the tissues. In response, small blood vessels leak fluid, which then accumulate in the skin. The said mediators cause a blown up response leading to hives and red welts. [11, 12]
Manifestations of Dermatographism
Aside from the red, raised rashes at the site of skin stroking, patients may present with pruritus or burning sensation. These usually develop less than five minutes after stroking the skin. It can persist for as long as fifteen to thirty minutes, longer than that of a normal skin, which usually subsides in the next five to ten minutes. [2, 4]
Other forms of dermatographism, particularly that of the delayed pressure urticaria, may differ. Instead of itching, this may usually present with a burning sensation. Along with this, its rashes remain longer, for a number of hours after exposure to the triggering stimulus. 
Types of Dermatographism
Dermatographism comprise a variety of features. These differ in morphology, but similar in that the rashes appear after the skin has been stroked.
Immediate Symptomatic Dermatographism (Factitious Urticaria)
Known as the most common type of dermatographism, it is characterized by severe pruritus. It is usually found among adolescents, and is associated with the human leukocyte antigens: HLA A2, B16, A1 and B5. [2, 13]
In this type, discrete, urticarial skin lesions are present on a surrounding area of erythema. The rashes can be further described as transient, follicular, and popular in character. 
Associated to cholinergic urticaria, this type is comprised of papular lesions and wheals. It may occur in groups and clusters, and if severe, may even present as purpura. [2, 15]
It is a rare type of dermatographism. Rubbing of skin in a repeated and persistent manner serves as a stimulus. Skin lesions are characterized as tiny, punctuate wheals. [2, 16]
Cold Precipitated Dermographism
This type can be brought about by low integumentary temperature. This type of dermatographism can be induced on a previously cooled skin. [2, 17]
Eliciting and Diagnosing Dermatographism
Diagnosis is usually based on a thorough history and physical examination. It is usually confirmed by observing the clinical response after eliciting a moderate pressure to stroke or scratch against the skin. A spring loaded stylus (dermographometer) can also be utilized in applying a constant, reproducible pressure and recording skin responses. With a pressure of 3600g/cm2, this is usually used for research purposes. [2, 11, 12]
A moderately pressured scratching of skin can elicit dermatographism.
Dermatographism Treatment and Remedies
- The management for dermatographism can be done with the following measures: [2, 12]
- Antihistamine medications could inhibit the unregulated histamine response in dermatographism.
- Proper skin care and moisturization to prevent further dryness and subsequent pruritus.
- The medication Cromolyn stabilizes cell membrane and prevents excessive release of histamine.
- Avoidance of physical stimuli that can precipitate the condition.
- Reduction of anxiety and stress can further prevent occurrence of dermatographism.
Myths on Dermatographism: Questions Answered
Is Dermatographism a Type of Hives?
Yes. It is also called dermatographic urticaria, and is one of the more prevalent forms of physical hives. 
How Long Does Dermatographism Last?
Dermatographism vary on a case to case basis. It can last from a few months to even a lifetime. 
Can a Previous Hypersensitivity Reaction to A Medication Trigger Dermatographism?
Yes, an allergic reaction to either a drug, food, or even an exposure to an irritant can cause dermatographism. 
Can Dermatographism Occur Among Children?
Yes, it can. Dermatographism does not choose any age, and can happen in almost every age group. It can occur among infants, and even among elderly. 
Can Allergy Skin Tests Be Used In Diagnosing Dermatographism?
No. Dermatographism is a response to a trigger, it is not an allergy. Measuring the level of immunoglobulin ET would not be appropriate, and would just be irrelevant for dermatographism. The pressure in the skin during an allergic skin test shall only elicit a wheal as a response. Hence, a false positive result of the test. 
Does Dermatographism Increase One’s Risk of Having Cancer?
No. No sufficient evidence exist proving that dermatographism is indeed related to malignancy. 
- Jedele, KB, et al. Familial Dermographism. American Journal of Medical Genetics. 1991; 39: 201-3.
- Bhute, D, et al. Dermatographism. Indian Jourmal of Dermatology, Venereology and Leprosy. 2008; 74: 177-9.
- Kontou-Fili, K, et al. Physical Urticaria: Classification and Diagnostic Guidelines: EACCI Position Paper. Allergy. 1997; 52: 504-13.
- Warner, D, et al. Famotidine(pepcid)-induced Symptomatic Dermatographism. Journal of American Academy of Dermatology. 1994; 31: 677-8.
- Andrews Diseases of the Skin: Clinical Dermatology, Dermatographism. 10th edition. p. 153.
- Morfvn, M, et al. Reactive Polyarthritis and Painful Dermatographism Caused By Helicobacter pylori. Review of Allergy Mexico. 2002; 49:99-102.
- Cooper, M, et al. Hypereosinophilic Syndrome: Long-Term Remission Following Allogeneic Stem Cell Transplant In Spite of Transient Eosinophilia Post-Transplant. American Journal of Hematology. 2005; 78:33-6.
- Salazar Villa, et al. Symptomatic Dermatographism and HLA Antigens. Review in Allergology. 1992; 39: 89-95.
- Soter, N, et al. Urticaria and Angioedema. Fritzpatrick’s Dermatology in General Medicine. 6th edition. New York: Mc Graw-Hill; 2003. p. 1129-43.
- Grattan, C, et al. Urticaria and Angioedema. Textbook of Dermatology. 7th edition. Oxford: Blackwell Science. 2004; 47: 1-37.
- Smith, JA, et al. Dermatographia Caused By IgE mediated Penicillin Allergy. Annals in Allergy. 1983; 51: 30-3.
- Kaplan, Ap. Unusual Cold-Induced Disorders: Cold- Dependent Dermatographism and Systemic Cold Urticaria. Journal of Allergy and Clinical Immunology. 1984; 73: 453-6.