Therapeutic Options For Chronic Urticaria

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Therapeutic Options For Chronic Urticaria

• Jack B. Cohen, DO
• Assistant Professor
• Department of Dermatology
• UT Southwestern Medical Center
• Dallas, TX

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Urticaria

• Urticaria or hives Pruritic, pale red to
  brightly erythematous papules and plaques that
  appear in crops. The areas may coalesce to form
  polycyclic or bizarre shaped areas. Individual
  lesions will last lt 24 hours.
• Angioedema Edema in the deep dermis and SQ
  tissues causes massive swelling of the eyelids,
  lips, tongue, pharynx, penis, scrotum, hands and
  feet. The overlying skin is normal. 50 of cases
  have urticaria also.

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Urticaria
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Urticaria
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Angioedema
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Urticaria

• Course Most case are self-limiting lasting days
  to weeks. Chronic urticaria are hives that last
  gt 6 weeks.
• Age Any
• Etiology Idiopathic urticaria accounts for 50
  of the acute cases and gt80 of chronic urticaria
  cases. Foods, drugs, infections, malignancies,
  physical causes, insect bites, thyroid
  antibodies, and inhaled allergens have been
  implicated.

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Urticaria

• Immunologic urticaria
• A. IgE-dependent
• Specific antigen sensitivity (foods, drugs,
  pollens, parasites, bee venom)
• Atopic diathesis
• Physical (dermatographism, cold, solar,
  cholinergic)
• Idiopathic- IgE binding site autoantibodies

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Urticaria

• Immunologic Urticaria
• B. Complement-mediated
• 1. Hereditary angioedema
• 2. Serum sickness
• 3. Reactions to blood products
• 4. Angioedema with lymphoma

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Urticaria

• Non-immunologic urticaria
• 1. Direct mast cell releasing agents
  (opiates, curare, radiocontrast media,
  polymyxin B)
• 2. Arachadonic acid alterating agents (ASA
  and NSAIDS)

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Urticaria

• Physical Urticarias Dermatographism is the most
  common found, where stroking or rubbing the skin
  causes histamine release and linear hives within
  minutes. Localized cold, heat, solar exposure,
  and vibration have uncommonly caused localized
  hives. Cholinergic urticaria are small wheals
  that itch intensely on the trunk and neck,
  induced by exercise, sweating, or hot showers.

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Urticaria

• Provacative tests for physical urticarias
• Dermatographism Stoke with finger
• Cold urticaria Ice cube
• Cholinergic urticaria Exercise
• Pressure Apply tourniquet
• Solar Sun or UVB light exposure
• Vibratory Hold massager
• Contact Open patch test and read at 30 min.

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Dermatographism
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Cold Urticaria
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Urticaria

• Hereditary Angioedema A rare, autosomal
  dominant disorder with recurrent spontaneous
  episodes of non- pitting edema of the skin
  especially the face and extremities, upper
  respiratory tract, and GI tract. There is no
  itching. The condition is caused by a C1
  esterase inhibitor deficiency or lack of
  function. Asphyxiation is a possibility from
  laryngeal edema.

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Urticaria

• Urticarial Vasculitis
• This is a condition where individual urticarial
  lesions last greater than 24 hours, often have
  petechiae, and leave behind hyperpigmentation.
  Burning symptoms accompany the itching and there
  is often joint pain with effusions. 50 of cases
  are idiopathic, but urticarial vasculitis may be
  associated with systemic lupus erythematosus or
  hypocomplementemia.

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Urticarial Vasculitis
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Urticaria

• Differential diagnosis
• Papules Insect bites, papular urticaria, and
  pruritic urticarial papules and papules of
  pregnancy (PUPPP).
• Plaques Erythema multiforme, urticarial
  vasculitis, urticarial bullous pemphigoid,
  dermatitis herpetiformis, and urticaria
  pigmentosa (mastocytosis)

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Insect Bite and Papular Urticaria
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Erythema Multiforme
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Urticaria Pigmentosa
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Urticaria

• Laboratory- only indicated with chronic
  urticaria!!
• CBC with diff
• Metabolic panel
• Sed rate
• TSH, anti-microsomal and anti-thyroglobilin
  antibodies.
• Stool for ova and parasites, if eosinophilia
  present on CBC.
• ANA, only if other lupus criteria present.

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Urticaria

• Laboratory
• If angioedema is dominant, check a C4 level, and
  if low order a C1 esterase inhibitor level.
• A skin biopsy is indicated
• a. If individual urticaria last greater than 24
  hours, and/or petechiae or hyperpigmentation are
  present to rule out urticarial vasculitis.
• b. If you suspect another diagnosis.
• c. If you are unsure of the diagnosis.

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Urticaria

• Treatment
• Treatment is for symptomatic lesions.
• Eliminate a food, medication, or other cause if
  it can be be determined.
• In the physical urticarias avoid the triggers,
  cold, scratching, etc.

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Urticaria

• Is it something Im eating?
• In acute urticaria, foods are frequently the
  cause, but less so in chronic urticaria.
• The most allergenic foods are chocolate,
  shellfish, fish, nuts, peanut butter, tomatoes,
  strawberries, melons, pork, cheeses, garlic,
  onions, and spices.
• Food additives may cause urticaria. Yeasts,
  salicylates citric acid, benzoic acid, and the
  azo dyes, like the yellow dye tartrazine and
  related green and red dyes.

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Urticaria

• Intradermal tests are untrustworthy, as there are
  frequent false positives and negatives.
• RAST testing is more specific.
• Some authors propose elimination diets for
  chronic urticaria, but these are rarely helpful.

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Urticaria

• Medications are often the cause including many
  antibiotics, anti-inflammatory drugs, hormones,
  anti-hypertensives, and biologics such as insulin
  or blood products.
• 1. Discontinue any medications that coincide
  with the onset of the urticaria.
• 2. Discontinue all unnecessary medications,
  including vitamins, health food supplements,
  ASA, NSAIDS, and OTC products.
• 3. Discontinue angiotensin converting enzyme
  inhibitors, especially if angioedema is present.

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Urticaria

• Treatment
• Search for and treat any underlying infection
  gum disease tooth abscess, sinusitis, tinea,
  scabies, gastrointestinal parasites, chronic
  urinary tract or pulmonary infections.
• Cool showers and compresses.

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Urticaria

• Treatment
• 6. H1 anti-histamines are the mainstay of
  therapy!!
• Often more than one anti-histamine from
  different classes may be required.
• The non-sedating anti-histamines fexofenadine
  (Allegra) 60 mg bid or 180 mg qd , loratadine
  (Claritin) 5 10 mg qd, or desloratadine
  (Clarinex) 5 mg qd can be effective.

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Urticaria

• Treatment
• Cetirizine (Zyrtec) 10 mg qd also is effective
  and is less drowsing than the older shorter
  acting antihistamines, but these are still
  effective medications
• Hydroxyzine HCl (Atarax) 10-25 mg q6h
• Diphenhydramine (Benadryl) 25mg q6 h
• Clemestine (Tavhist)1.34-2.68 mg q12h
• Cyproheptadine (Periactin) 4mg q6-8h

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Urticaria

• Treatment
• 7. The tricyclic anti-depressants doxipen
  (Sinequan, Adaptin) 10-100 mg qhs bid, or
  amitriptyline 10 -100g qhs can be added to the H1
  anti-histamines, especially when patients wake up
  from itching.
• 8. H2 anti-histamines cimetidine and ranitidine
  have also been added with limited success.

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Urticaria

• Treatment
• 9. Corticosteriods
• IM dexamethasone (Decadron) 4-8 mg can be given
  for quick relief from severe urticaria or
  angioedema, while waiting for the anti-histamines
  effects to begin.
• Tapering oral corticosteroids courses ideally
  should be given for less than 3 weeks.
• If corticosteriods are used longer, the doses
  should be equivalent to prednisone 10 mg/d or
  less.

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Urticaria

• Treatment
• 10. The leukotriene inhibitors monozuklast
  (Singulair) 10 mg qd and zafirlukast (Accolade)
  10 - 20 mg bid have been used with varying
  success.
• 11. Colchicine 0.6 mg bid tid and Dapsone 25
  100 mg bid can be useful in chronic urticaria,
  where the biopsy shows PMNs or in urticarial
  vasculitis.

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Urticaria

• Treatment
• 12. Anti-histamines Nifedipine (Procardia,
  Adalat) 10 mg tid
• 13. Anti-histamines Terbutaline (Brethine) 2.5
  5 mg tid
• 14. Immunosuppressives cyclosporine (Neoral) 100
  -150 mg bid or azathioprine (Imuran) 50 100 mg
  bid have been added in chronic urticaria to keep
  to corticosteroid doses down to a minimum.

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Urticaria

• Treatment
• 15. IVIG has been used in very resistant cases.