Management of Chronic Urticaria - Dermatology - Lecture Slides, Slides of Dermatology

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Management of Chronic Urticaria

Identifying Triggers and

Treating Symptoms

Chronic Idiopathic Urticaria (CIU)

• Consists of hives
• May be accompanied by angioedema
• Diagnosed when hives occur on a regular basis for

longer than six weeks

• Chronic urticaria improves with time

Photo Images of Hives

Prevalence

• 25% of the population affected at some time in their lives *
• 25% of urticaria cases chronic †

  • 6 weeks duration

• Over 75% of chronic cases idiopathic ‡
  • Affects 0.1% to 3% of population *

Impact on Quality of Life

• Restricted normal daily activities
• Restricted sleep, mobility, energy
• Increased pain, social isolation,

and emotional distress

• Reductions in quality of life similar

to patients with heart disease

Angioedema

• Swelling of lips, face, hands, feet, penis or scrotum
• Facial swelling most prominent in periorbital area
• May be accompanied by swelling of the tongue or pharynx
• Larynx virtually never involved

Urticaria/Angioedema

• Angioedema accompanies uriticaria in about 40% of

cases

• 40% of patients have hives alone
• 20% of patients have angioedema alone

Differential Diagnoses

• Dermatographism most common (linear hives lasting

30 minutes to 2 hours)

• Hives of urticaria last 4 to 36 hours
• Patients with chronic urticaria may have mild

dermatographism (hives of primary dermatographism much more severe)

Duration of Symptoms

• Longer than six weeks
• Helps rule out other identifiable causes – i.e., drug

reactions, food or contact allergy

• Exclusion diets have no effect on chronic urticaria or

angioedema but food allergy may cause acute urticaria

• 60% of chronic urticaria is idiopathic

• Showers and exercise
• Soaps, laundry detergents, fabric softeners
• Skin lotions, cosmetics, hair color
• Anxiety
• Medications (i.e., NSAIDs, oral contraceptives)

Urticaria: What Can Make it Worse?

Evaluation

• Few if any diagnostic tests needed
• If connective tissue disease suspected – ESR, ANA, skin bx
• Complement determination only for angioedema without hives to evaluate for Hereditory Angioedema
• TFTs may be indicated because of association between urticaria and Hashimoto’s (diseases occur in parallel)

Therapeutic Options

• H 1 receptor antagonists
• Combined H 1 and H 2 receptor antagonists
• Leukotriene antagonists
• Sympathomimetic agents
• Corticosteroids
• Experimental therapies

New Generation Antihistamines

Recommended Doses in CIU*

Product Children Adults

Cetirizine 2.5 to 10 mg daily †^ 10 mg daily

Desloratadine Not indicated 5 mg daily

Fexofenadine 30 mg twice daily ‡^ 60 mg twice daily

Loratadine 5 mg once daily** 10 mg daily

** 2-5 years † 6 months-11 years ‡ 6-11 years

Combined H 1 -H2 Receptor Antagonists

• 85/15 ratio of skin H 1 /H 2 receptors
• Combination of anti H (^) 1&2 provides additional

treatment benefit

• Doxepin blocks both receptors and is a more potent

anti-H1 blocker than diphenhydramine or hydroxizine

• Sedation may limit usefulness of doxepin