Large local reactions
Approximately 5% suffer from more severe skin reactions including large swellings of up to 10 cm in diameter as well as vesicles and blisters often proceeding to vasculitis and necrosis.86-88 The underlying pathomechanisms are not well investigated. They might represent type 1 late phase reactions, IgG-mediated type III Arthus reactions, or pure type IV reactions.86-88 Especially in children, skin lesions may be accompanied by fever, malaise, and lymphadenopathy.89 Papular urticaria describes a generalized type 4 hypersensitivity characterized by chronic recurrent eruptions due to the bites from fleas and other insects.90,91 The disease causes significant morbidity, especially in children from tropical countries.