Ali Ahmed Shaju, Samin Sadaf, Md Hasanuzzaman, Noushin Nawal
Chronic symptomatic dermographism is a challenging dermatologic condition characterized by recurrent wheals triggered by nonspecific physical stimuli, and management typically begins with H1-antihistamines, escalating as needed, with anti-IgE therapy such as omalizumab reserved for refractory cases based on clinical response rather than serum IgE levels. We report a 20-year-old male with a long-standing history of symptomatic dermographism and childhood atopy, provoked by minimal mechanical stimuli such as friction from clothing or light stroking of the skin, which significantly impaired his daily activities and academic performance. Diagnosis was made clinically and by exclusion of systemic disease, with laboratory investigations revealing fluctuating serum IgE levels over multiple measurements, ranging from markedly elevated to near-normal, without correlation to disease severity, highlighting the limitations of using IgE to guide therapy. Standard management included up-dosed second-generation H1-antihistamines (up to fourfold the standard dose) and intermittent short courses of oral corticosteroids resulting in partial disease control. Omalizumab was considered but not initiated, as partial clinical improvement was achieved without meeting criteria for refractory urticaria. Despite ongoing therapy, the patient continued to experience recurrent urticarial episodes during follow-up, although with reduced frequency and severity. The case emphasizes phenotype-driven management in chronic symptomatic dermographism and the limited role of IgE in therapeutic decision-making.