I started writing an emergency protocol back in 2015 when my mast cell reactions were scaring me with their unpredictability. I wanted something comprehensive, in writing, for anesthesia teams in the case of a planned surgery, but also something that my husband could hand to paramedics or emergency room doctors, if I couldn’t speak for myself. It was a massive undertaking because I tracked down every link and reference I could find about medication and surgery precautions for patients with mast cell diseases and ME. I wanted to gather all the information that was pertinent to me — my particular case — and edit it down to something manageable. I put together something passable and then moved it to the back burner for the last 4 years.
Last week I saw a new GI doctor who was emphatic that I get a colonoscopy and endoscopy at the same time and with anesthesia. I have been completely enema-dependent for years and, honestly, it’s exhausting. My previous GI doctor told me it was due to anatomical abnormalities (an MRI found pelvic floor dysfunction with cystocele, rectocele, sigmoidocele) and that I’d likely need enemas for the rest of my life, but it feels like the issues are getting worse and the new doctor didn’t want to throw medications at the problem without knowing exactly what she’s dealing with.
I cannot imagine voluntarily going under anesthesia. All of my worst reactions in the past 7 years have been to medications and my fear of trying new ones — especially intravenous medications — is so pronounced that I vowed only to agree to anesthesia if I was in a life-threatening situation (or couldn’t speak for myself). How could I be lying on a gurney with a peripheral IV, knowing they are about to inject multiple anesthetic drugs and not jump up and run out of the room? I wouldn’t be able to advocate for myself… I could die for a colonoscopy! So, I left the appointment with a sense of doom that only deepened when I started to feel a new ache in my lower abdomen. It got progressively worse over 3 days, the ache turned to pain and, what I thought of as run-of-the-mill bowel inflammation started to seem like something else. Gallstones? Bladder infection? I got out my emergency protocol notes and spent about 20 hours over the next few days rewriting everything, feeling like I might be working against the clock if this was something like appendicitis. Then I woke up last Sunday to such severe lower abdominal pain that I couldn’t move, could barely breathe or speak. I was shaking all over, in a cold sweat, nauseous and felt like I was on the brink of passing out. My husband wanted to call an ambulance, but I said no, hoping it was some sort of spasm that would pass. And it did… but not entirely. The ache and twinging remained for a few more days. It’s gone now and I think it was my dastardly bowels, after all, but it was bad and it scared me. It’s like the gods heard me say, “no way am I getting a colonoscopy” and decided to stab and twist their Elizabeth voodoo doll to make sure I got the point that there’s a problem I can’t continue to ignore.
The upshot of all this is, I finished the emergency protocol and I wanted to share it here, in case it could be useful to anyone else. There are a few important points about it, though:
- When I started, it was for personal use and I didn’t keep track of references. I will go back and gather all the links and add them to this article, but I have no idea how long it will take me and I wanted to share this sooner, rather than later. If you see your own information here without credit, please understand I will add a link to your article/blog/website! If you want me to do it asap, feel free to leave a comment.
- This protocol concentrates heavily on mast cell precautions because MCAS has caused my life-threatening reactions such as anaphylaxis and profound hypotension. It does not mention ME or CFS, although I researched and included ME resources, such as Dr. Lapp’s recommendations (Appendix E of the Primer for Clinical Practicioners).
- I have an EDS diagnosis (Ehlers-Danlos Syndrome — a connective tissue disorder), which can cause serious surgical complications. There are a lot of guidelines out there for EDS patients and, as yet, I have not researched any of them. It wasn’t until recently that I started to take this diagnosis more seriously and I still haven’t had the gumption to jump down the research rabbit hole, but, once I do, I will be updating my surgery protocol with any additional EDS precautions that are pertinent to my situation.
- It bears repeating: This is not medical advice of any kind. This is my personal protocol, for my personal situation. You may be more or less reactive than I am, you may have normal or high blood pressure or you may be far more disabled and need many more accommodations… But, I hope it can be of use as a jumping-off point. Please consult with your doctor.
- The link below is a printable pdf file, which is formatted properly, but I also wrote the protocol in its entirety on this page so others could copy and paste anything they wanted into their own protocols.
The most important considerations in emergency situations and for surgery are:
- My reactivity and hyper-sensitivity to medications, which necessitates very low dose and slow administration (see attached allergy list — I have reacted to Morphine and Morphine derivatives with breathing difficulties).
- I HAVE NEVER HAD ANESTHESIA and cannot predict how I will respond to medications.
- Maintaining my very low blood pressure.
- My history of idiopathic and atypical anaphylaxis with syncope.
- Avoiding vasodilators and histamine-releasing agents.
- I have cervical spine instability and care must be taken not to damage or hyperextend my neck.
For a patient with mast cell disease, the stress of surgery is compounded by the possibility of complications such as anaphylaxis, cardiovascular collapse, increased bleeding and even death. Therefore, general anesthesia is considered a high-risk procedure in patients with mast cell disease. It is critical that all members of the patient’s operating team take proper precautions before, during, and after surgery to protect against potentially life-threatening mast cell reactions.
An experienced anesthesiologist is aware of medications known to cause mast cell degranulation and medications that stabilize mast cells. If the patient is satisfied that their anesthesiologist fully understands the importance of planning around mast cell disease, it will go a long way toward calming the patient, which in turn may reduce mast cell mediator release. Bear in mind that some of the most common mast cell triggers are medications, pain, stress, hormones, temperature extremes, molds, perfumes, cleaning products and detergents.
Review medication and supplement list with the surgical team. I will stop as many medications and supplements as possible at least a week in advance, especially ones that lower blood pressure (vasodilators such as aspirin, nitroglycerin, vitamin E).
Discuss premedications. Some procedures require the patient not to take anything by mouth including medications after midnight the night before surgery. In this case, discuss administering H1- and H2-blockers intravenously prior to the surgery (note: I have never had IV antihistamines, so this is a concern). Premedication with corticosteroids may also be indicated. Ask anesthesia team and surgeon if I am allowed to drink clear fluids before surgery and be sure to be adequately hydrated.
Discuss medications that will be used during surgery. I have mast cell activation syndrome and a history of idiopathic anaphylaxis. Anaphylactic episodes are generally treated with intravenous H1- and H2-blockers and IM epinephrine, if there is hemodynamic instability or respiratory distress. In addition, IV fluids and other support and resuscitation measures should be undertaken.
I am unusually reactive to small amounts of medications. All medications should only be used if absolutely necessary and then used sparingly and in small doses until my response can be assessed. For example, I have had reactions to every benzodiazepine I’ve tried (tongue swelling, respiratory distress, migraine) and am very sensitive to even antihistamines. I have autonomic nervous system dysfunction. Due to this, anesthetics can cause gastro-esophageal reflux, tachyarrhythmias and difficulty maintaining blood pressure. It may be prudent to perform a graded challenge procedure in the hospital under the supervision of an allergist and an anesthesiologist for certain medications if there is no history of exposure to that medication. This procedure usually starts with scratching the skin with a small amount of medication followed by injection of increasing amounts with careful monitoring after each injection.
I have very low blood pressure and probable depleted blood volume. Intraoperative hypotension is one of the most encountered factors associated with death related to anesthesia. Consider an intra-arterial catheter for continuous blood pressure monitoring during surgery (as opposed to a cuff). Discuss how hypotension will be treated during surgery (print study).
Controlling the depth of anesthesia limits the hypotensive effect of anesthetic drugs. Deep hypnosis (BIS <45) has been associated with postoperative complications and mortality. To limit hypotension induced by intravenous drugs, anesthesia should be titrated to clinical response. To guide induction anesthesia and identify the depth of anesthesia, consider bispectral index (BIS) monitoring.
Discuss continuous IV hydration to maintain blood pressure, however, please note that I have had reactions to IV fluids in the past due to running them too quickly or the saline being too cold. I typically run 1 liter of B. Braun Excel normal saline over a maximum of 4 hours. Fluids should be warmed in a 35-40 degree celsius water bath.
Discuss pain control: I have had reactions to Morphine and its derivatives and NSAIDS.
I have low cortisol and take daily low-dose hydrocortisone. Consider a 24-hour urine free cortisol level before and after surgery. A liver panel and serum cortisol should also be checked prior to any general anesthesia. I will double or triple my hydrocortisone dose before and after surgery.
Check serum electrolytes, in particular red blood cell magnesium (an intracellular test) and serum potassium and replenish if borderline or low. Low magnesium or potassium depletion could potentially lead to cardiac arrhythmias under anesthesia. Consider potassium 10 mEq, 1 tablet BID, and magnesium sulphate 50% solution, 2cc. IM 24 hours prior to surgery.
I have sleep apnea and asthma. Discuss the use of oxygen throughout procedure (use a disposable mask, not a reusable one in case of sensitivity to disinfectants). A preoperative lung vital capacity could be helpful. (The marker for real difficulty is thought to be a VC <1.0 liter. Such a patient needs good pulmonary preparation before surgery and a plan for postoperative ventilatory support.)
Discuss possible airway difficulties (review C-spine flexion-extension MRIs, if needed), such as: neck pain, cervical spine subluxation, limitation of cervical spine movement, nerve root impingement and/or spinal cord compression. I have a diagnosis of Ehlers-Danlos syndrome (EDS), TMJ disorder, cervical spinal stenosis, degenerative disc disease in my cervical spine and a previous neck injury. Care must be taken to keep my head and neck in a neutral position during surgery. Discuss wearing a soft neck collar to reduce neck hyperextension; this might help minimize inadvertent stretching of my neck muscles during intubation or use of an endoscope. To avoid neurological damage, patients with cervical spine instability should generally be intubated and positioned awake before surgery. This can also help assess the possibility of arytenoid involvement and determine the size of the glottic opening. The TMJs must be examined to ensure that mouth opening and anterior subluxation of the mandible will permit direct laryngoscopy/intubation. Also, be aware that the larynx may be displaced from its usual location by erosion and generalized collapse of the cervical vertebrae.
Pressure dressings are indicated even for minor procedures because excessive bleeding is common in mast cell disorders, even when blood counts are normal (this is related in part to the release of heparin during mast cell degranulation). For major procedures, a history of mast cell disorder should be included in bleeding risk assessment and may require special protocols. (I have included this in During Surgery discussion, also.)
The surgical team should be aware that I should not be exposed to perfume or scents at any time before, during or after the procedure.
Discuss post-operative recovery accommodations in the hospital, if needed — see After Surgery section.
Constant attention from the anesthesiologist is required for the safety of a patient with mast cell disease, as some symptoms of mast cell mediator release such as flushing, hives, and early signs of obstructed breathing can be masked by surgical drapes and airway tubes.
Prior to the administration of any drugs associated with surgery, it is important that an IV is running, epinephrine is available for immediate intramuscular (IM) or IV administration, and emergency resuscitation equipment is easily accessible in case of an adverse reaction.
Be sure the patient does not become either too cold or overheated. I have subnormal body temperature (typically ~97.7). Warm blankets should be used and all IV fluids should be warmed (not over 40 degrees Celsius) before they are given. In addition, there should be a minimum of noise and bustle prior to the administration of the anesthetic in order to reduce the possibility of anxiety-triggered mast cell mediator release.
Intravenous (IV) fluids should be continuously running to keep the patient well-hydrated in all surgeries involving general anesthesia or conscious sedation. Hypovolemia resulting from blood loss or dehydration is a frequent cause of hypotension in the perioperative setting. IV access will also make it possible to immediately administer any emergency medications that may be needed. Hypotension episodes should be promptly treated by intravenous vasopressors — and/or antihistamines/epinephrine, in the case of anaphylaxis.
Although the diagnosis of anaphylaxis usually depends on the involvement of 2 organ systems, even if it presents with 1 organ system, such as the skin, epinephrine administration may be indicated. Anaphylaxis may present as an acute cardiac or respiratory event, with hypotension as the only manifestation. Should anaphylaxis occur during surgery, the drug thought to be responsible should be discontinued immediately and rescue medications should be administered (H1 and H2 antihistamines, corticosteroids, airway support with 100% oxygen, IV replacement fluids to compensate for dilated blood vessels, bronchodilators). Because of the risk of potentially lethal arrhythmias, IV epinephrine should only be administered in profoundly hypotensive patients or patients in cardio/respiratory arrest who have failed to respond to IV volume replacement and several IM doses of epinephrine. *I am extremely sensitive to epinephrine, so even IM epinephrine should only be used if completely necessary. I am also extremely sensitive to antihistamines, so care must be taken to use the lowest dose possible and push very slowly. Vigilantly monitor me for reactions to rescue medications, also.*
*See anaphylaxis protocol below*
It is important to keep in mind that not all hypotensive episodes during surgery are due to mast cell degranulation/anaphylaxis. It would be ideal to get blood tests during a reaction, especially tryptase (see recommended tests below).
One of the most important considerations during anesthesia is maintaining a neutral neck position. A hyperextended neck can increase spinal cord compression and this, coupled with hypotension, which decreases blood flow to the spinal cord, can have a severe effect. Due to EDS and osteoporosis, my head, neck, pelvis and limbs should be moved carefully (limbs kept close to my body).
Excessive bleeding is common in mast cell disorders, even when blood counts are normal. Pressure dressings are indicated even for minor procedures.
If the patient is being admitted to the hospital, discuss what is needed for a safe recovery:
- Request a private room or a sound-proof door (versus an open curtain) and placement on a quiet ward.
- Explain any sound, light, or chemical/fragrance sensitivities and the need for scent-free nurses (a sign next to the patient’s door can help remind nurses changing shifts).
- Discuss any food sensitivities.
- Discuss temperature sensitivities and the need for extra blankets or adjustment of the thermostat.
- Ask whether it’s possible to minimize nighttime disruptions (for example, middle of the night blood pressure monitoring).
- Discuss the potential need for extra recovery time in hospital or for a reclining wheelchair or gurney during discharge from the hospital.
- Bring your own soap, hand sanitizer and bedding.
Consider using (but administer with extreme caution):
- Diprivan (propofol) as the induction agent. (However, Propofol, used alone at induction of anesthesia, promotes a significant decrease in arterial blood pressure compared with thiopentone or etomidate, even with reduced doses.)
- Versed (midazolam)
- Fentanyl (a short-acting narcotic; may require adjunct treatment with Zofran)
- Droperidol (an anti-nausea agent)
Second choice is ketamine or benzodiazepines, such as midazolam (however, I have had reactions to benzos in the past).
Atarax (Hydroxyzine) should only be used in an emergency. It can cause heart palpitations and arrhythmias. Doxepin should only be used at very low doses (<5mg — I have never taken it).
A small amount of Diazamuls, a preservative-free Valium emulsion, could be considered for long surgeries where the possibility of “awareness” is a concern. This drug can also be used pre- and post-operatively for sedation, and for cramping in certain types of procedures.
Use IV preparations without preservatives or alcohol. Use B. Braun Excel normal saline. Do not use lactated ringers, if possible.
Oxygen should be used throughout procedure (possibly at 5 liters pre and post-operatively).
Do not use epinephrine except in life-saving situation. But Epinephrine must be on hand during the procedure.
Do not use medications that contain preservatives, artificial colorings, dyes, flavorings or alcohol (topical alcohol, as in alcohol prep pads, is fine, as is povidone iodine). Single-use vials are usually preservative-free.
Do not use medications that stimulate neurogenic syncope or lower blood pressure:
- No cathecholamines (Epinephrine)
- No sympathomimetics (Isoproterenol)
- No vasodilators (nitric oxide, nitroglycerin, alpha-blockers, and hypotensive agents)
I have orthostatic hypotension (OI), chronically low blood pressure and a history of vasovagal syncope. Many people with dysautonomia have low plasma volumes, low RBC mass, and venous pooling and the above drugs may cause or exacerbate these conditions.
Do not use histamine-releasing anesthetic agents:
- No Sodium Pentothal or other thiobarbituates (Thiamylal, Thiobarbital etc.)
Do not use histamine-releasing muscle relaxants:
- No muscle relaxants in the Curare family, such as Tracrium and Mevacurium.
- No Succinylcholine ((Anectine) often causes severe, generalized muscle pain, post-op.)
- No D-tubocurarine
- No Metocurine
- No Doxacurium
- No Atracurium
- No Mivacurium
- No Rocuronium
Muscle relaxants are the most likely group of the anesthetic drugs to cause anaphylaxis. If muscle relaxants must be used, the current recommendation is to start with a quarter to half the usual dose of whatever you’re using. Intraoperative neuromuscular monitoring helps prevent overdose. Consider using “nondepolarizing” muscle relaxants, such as pancuronium or vercuronium.
Do not use anesthetic gasses:
- No Halothane
- No Enflurane
- No Isoflurane
- No Desflurane
These can cause problems for patients with chemical sensitivities and are highly hepatoxic. An alternative might be continuous IV infusion of a short acting anesthetic by injection or a continuous flow pump. If necessary, consider Sevoflurane.
Do not use:
- No Morphine, codeine or morphine derivatives
- No Opioids
- No Vancomycin
- No Ethanol
- No Dextran
- No Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and Toradol
- No Polymyxin B
- No Amphoteracin B
- No Quinine
- No Dextromethorphan
- No Alpha-adrenergic blockers
- No Beta-adrenergic blockers
- No Anticholinergic drugs, if possible, such as Hydroxyzine and Cimetidine
- No decongestants, cold or flu medications
- No SSRIs
Do not use local anesthetics, if possible. If needed, do not use ones with preservatives or epinephrine:
- No Procaine
- No Chloroprocaine
- No Tetracaine
- No Benzocaine
Antibiotics are not well tolerated by mast cell patients, however, these are some that have been reported as safest by patients (use with caution):
- Azithromycin (Z-pak)/Zithromycin/Zithromax
- Beconase AQ
- Biaxin (eg. Clarithromycin)
MEDICAL EMERGENCY RESPONSE PLAN for Mast Cell Activation and Anaphylaxis:
If the patient presents with flushing, rash, hives, swelling, abdominal pain, nausea, vomiting, shortness of breath, wheezing or hypotension, respond with the following:
- Epinephrine (preservative-free) 0.3 cc of 1:1000 (1mg/1ml) solution = 0.2mg–0.3mg IM (Vastus Lateralis muscle) and repeat 3x at 5–15 minute intervals if BP < 90 systolic (my BP averages 86/55).
- Benadryl (diphenhydramine) 25mg (max 50mg) orally, IM or very slow IV push, diluted in normal saline over 2-5 minutes. Can repeat every 2–4 hours.
- Solu-Medrol (methylprednisolone) 120mg (40mg for children under 12) IV/IM (I have never had Solumedrol, so monitor closely. My usual steroid is oral Prednisone 6mg)
- H2 antagonist, such as Famotidine IV, should also be given (I have never had this, either — my usual H2 blocker is oral Zantac 150mg).
- Oxygen 100% by mask or nasal canula.
- Albuterol nebulizatio,n if wheezing present.
- IV fluids (warmed in 35–40 degree celsius bath and run as slowly as possible for the situation).
*All mast cell patients must be monitored for biphasic (rebound) reactions.*
Pre-medication for major and minor procedures:
- Prednisone 50mg orally 24 hours and 1–2 hours prior to surgery (I’ve never had more than 7mg)
- Benadryl (diphenhydramine) 25–50mg orally, 1 hour prior to surgery
- Zantac (ranitidine) 150mg orally, 1 hour prior to surgery
- Singulair (montelukast) 10mg orally (5mg for children under 12), 1 hour prior to surgery (I’ve never had Singulair)
*Note: my current premedication protocol is 25mg oral diphenhydramine (Benadryl brand dye-free capsules only), 150mg oral ranitidine (Zantac brand), 6mg oral Prednisone and 325mg acetaminophen (Tylenol brand).**
Drugs to be avoided:
- Aspirin and non-steroidal anti-inflammatory (NSAIDS) medications
- Morphine, codeine derivatives
LABORATORY TESTS TO RUN IN THE EMERGENCY ROOM DURING AN ACUTE MAST CELL REACTION OR ANAPHYLAXIS:
- Serum Tryptase — upon arrival in the ER and three hours later.
- 24 hour urines for:
- n-methyl histamine
- prostaglandin D2 ( PGD2)
- 11-beta prostaglandin F2 alpha (BPG-F2A)
- CBC with differential
- Chilled plasma histamine
- Chilled plasma prostaglandin D2 (PGD2)
- Chilled plasma heparin
- Serum chromogranin A
- Serum magnesium
If possible, hourly determinations of serum tryptase, plasma PGD2 and histamine, and spot urinary PGD2 and N-methylhistamine should be pursued at baseline and over the next 2–3 hours as a reaction evolves.
SPECIMEN HANDLING ISSUES:
The short half-lives and thermolability of many mast cell (MC) mediators require continuous specimen chilling throughout collection, storage, and transport. Particularly with regard to 24-h urine collections for MC mediator testing, patients should be carefully educated to pre-chill the collection container overnight before beginning the collection and then to keep the container continuously chilled while following an otherwise standard 24-h urine collection protocol; the container should be removed from the refrigerator or ice chest only when imminently needed and should be returned to chilling as soon as possible. Patients should also be cautioned to maintain the container in a chilled environment throughout transport. We recommend the container be placed in a bag filled with ice and sealed, with the bag then placed in an ice chest filled with ice and sealed for transport to the accessioning lab, whereupon the bag can be removed from the chest and provided to the technician with a reminder of the criticality of keeping the specimen chilled. Laboratory staff often are unfamiliar with MC mediator testing, previously a rarely undertaken endeavor. Consideration should be given by the diagnostician to sharing with laboratory personnel the ultimate clinical goal of such testing and the importance of maintaining thermal integrity of these specimens at all times, including at the time of initial accessioning as well as when packing specimens for transport to reference laboratories that may be thousands of miles distant, transits that may involve long periods sitting in unventilated cargo containers on hot tarmacs. Use of well-insulated containers, and liberal placement of cold packs in the insulated container, should be de rigueur when packing such specimens for long-distance transport.
You MUST have your allergist or primary care provider sign the bottom of this form stating that
he or she will be responsible for the follow-up on the 24 hour urine collections. Otherwise, the ER physicians will be reluctant to order them since they cannot be sure of follow-up care. Remember to contact your physician for follow-up after discharge.
I agree to provide follow-up care for my patient,____________________________________, and will obtain the results of the 24-hour urine collections that were initiated in the emergency room setting and will provide appropriate care based on the results.
Printed Name of Physician
Signature of Physician Date
KOUNIS SYNDROME IN MAST CELL PATIENTS
Acute coronary syndromes can occur in allergic and anaphylactic reactions. One example, called Kounis Syndrome, is highly likely in patients with a wide variety of mast cell activation disorders and can affect patients of any age. The main triggers of Kounis syndrome are drugs, environmental exposures, and various pre-existing conditions. When patients are on a protocol exposing them to many medications, the cascade leading to anaphylaxis and Kounis syndrome can be very rapid, with the heart and coronary arteries as the primary target. Multiple mast cell mediators have direct action on coronary vessels and together result in hyperresponsiveness of mast cells, which can result in the Kounis syndrome cascade. Please note: Coronary artery spasm induced by mast cell mediators may initiate Takotsubo Syndrome or stress-induced cardiomyopathy during anaphylactic reactions.
Type 1: Normal coronary arteries, no coronary disease, no predisposing conditions; acute allergic attacks resulting in coronary vasospasms without elevations in cardiac enzymes OR coronary vasospasm with myocardial infarction with elevation of cardiac enzymes and troponins.
Treatment of the allergic episode can terminate the type 1 variant
- H1 and H2 blockers
- Vasodilators such as calcium channel blockers and nitrates can decrease hypersensitivity induced vasospasms
Type 2: Quiescent pre-existing atheromatous disease in whom acute allergic attacks can induce either vasospastic angina or plaque erosion, or rupture manifesting acute myocardial infarction.
Treatment of acute coronary event comes first, then treat allergic attack:
- acute coronary event protocol
- H1 and H2 blockers
Type 3: Stent thrombosis with eosinophils and mast cells identified on pathology (Giemsa, hematoxylin-eosin stain).
Treatment of stent thrombosis with allergic attack:
- H1 and H2 blockers
- Mast cell stabilizers
- Biopsy of thrombus stained for mast cells and eosinophils. Nitroglycerin causes decreased blood pressure and increased heart rate.
Fentanyl is the opiate with the best profile for mast cell patients; administer with extreme caution.
Nonimmunologic Histamine Releasers and Other Degranulation Triggers
|Foods and misc||Chemicals & Drugs||Physical Agents|
Calcium ionophore A23187
Spines & hairs of Caterpillars
MothsFoods high in Histamine or Tyramine, Gluten, Soy, Salicylates (eg: fish, strawberries, egg whites, tomato)
Foods containing preservatives, artificial colorings or flavorings.
Opiates (Codeine, Morphine, Percocet, Oxy etc)
NSAIDs (Advil, Motrin etc)
Polymyxin B sulfate
Trimethaphan and Trimetaphan
Iodine-based radiographic dyes
Neuromuscular blocking agents (eg: Dexamethonium, Gallamine triethiodide etc)
Dextromethorphan (cough suppressant)
Fungal infection drugs
Local anesthetics: lidocaine etc. (any amino amide-type)
|Dermatographia (Darier’s Sign)
Eating spicy foods
Solar light waves
Insect bites (Wasp, Hornet, Bee, Mosquito)
Smoke (wood burning, cigarette, marijuana) Scents/Odors/Perfume
Cleaning products and chemicals
Cosmetics/Creams containing salicylates
Preservatives, Additives, Dyes, Artificial flavours/colouring