Chronic idiopathic urticaria (hives) treatment

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Treatment of chronic or idiopathic urticaria involves use of antihistamine medications and avoidance of triggers or aggravating factors.

In the treatment of chronic idiopathic urticaria the principle approach is to control mast cells by suppressing IgE stimulation and/or the histamine release. Mast cells release three major types of histamines, H1, H2 and H3. As the skin contains both H1 and H2 histamine receptors, use of H1 and H2 antihistamines is usually considered for chronic idiopathic urticaria treatment.

Oral antihistamines for treatment of chronic idiopathic urticaria

     Oral antihistamines have been the first line treatment for all patients with chronic or idiopathic urticaria. Non-sedating 2nd generation H1 antihistamines are used with good treatment response. When itching is intense, especially in the night, sedative first generation H1 antihistamines are given in the night and non-sedating 2nd generation H1 antihistamines are given during the day for the idiopathic urticaria patient. Increasing the dosage up to four fold is recommended if the response to the initial dosage is found inadequate during chronic idiopathic urticaria treatment.

First generation H1 antihistamines for chronic or idiopathic urticaria
Chlorpheniramine, hydroxyzine, and diphenhydramine are the first generation H1 antihistamines having side effect of sedation. Though these antihistamines have proven record of efficacy in urticaria treatment, with the advent of second generation drugs their sedative effects appear as a big drawback in the treatment of chronic idiopathic urticaria.

Non–sedating 2nd generation H1 antihistamines in urticaria treatment
Loratadine, fexofenadine, cetirizine, levocetirizine, terfenadine, desloratadine and mizolastine are non sedating second generation H1 antihistamines very much in use in the treatment of chronic idiopathic urticaria.

Nonsedating H2 antihistamines for chronic idiopathic urticaria
Cimetidine, ranitidine, famotidine and nizatadine are H2 antihistamines having no sedating side effect. These drugs have been used successfully along with H1 drugs for the treatment of chronic or idiopathic urticaria.

Treatment of antihistamine –resistant chronic idiopathic urticaria

Some forms of chronic idiopathic urticaria do not respond well to antihistamine treatment. In some patients chronic idiopathic urticaria may become antihistamine -resistant. In such instances non antihistamine medications like systemic corticosteroids, leukotriene modifiers or immunosuppressants may be considered during urticaria treatment. However their use has many limitations due to their side effects.

Role for systemic corticosteroids
Systemic glucocorticoids like prednisone have been used for lessening swelling, inflammation and itch in chronic idiopathic urticaria. However they can be used only for a short treatment periods as they have serious side effects like Cushing syndrome, skin damage, increased blood glucose levels, sleep disturbances, weight gain and psychological effects. Corticosteroids can weaken the immune system and worsen the existing infections of patients with idiopathic urticaria.

Leukotriene modifiers for chronic idiopathic urticaria
     Asthma medications like montelukast and zafirlukast are  leukotriene receptor antagonists (LTRA). They have been found to be effective in the treatment of chronic idiopathic urticaria when used along with non–sedating 2nd generation H1 antihistamines like loratadine. Side effects of leukotriene modifiers include gastrointestinal disturbances, headaches, general hypersensitivity, insomnia, sleep disorders, aggression, anxiousness, hallucinations, depression, irritability, and increased bleeding tendency.

Immunosuppressant drugs
Immunosuppressant drugs like cyclosporine and cyclosporin G are useful in the treatment especially of chronic autoimmune urticaria. As immunosuppressants they suppress the activity of the immunological system by obstructing the activity and growth of T cells. Treatment with immunosuppressants may be associated with a number of potentially serious adverse drug reactions (ADRs) like gastrointestinal disturbances, peptic ulcers, pancreatitis, convulsions, kidney and liver dysfunction, increased vulnerability to opportunistic infections and flare-up of current infections. Ciclosporin is listed as IARC Group 1 carcinogens as sufficient evidence of carcinogenicity in humans has been established.

Maintenance treatment
Once the symptoms resolve the treatment must be continued and tapered off after three months. The dosage of the medication is gradually reduced every two weeks. In many cases relapse has occurred when the medication is withdrawn soon after the resolution of symptoms.

Topical agents
Certain topical agents like calamine lotion, menthol with aqueous cream, and crotamiton lotion have been found to soothe the inflammation and itching. Applying cold compress or ice to the affected area for about 15 minutes relieves swelling, itching and pain. This may be followed up with application of calamine lotion.

Considerations for children
There are specific approvals and restrictions by FDA for use of various antihistamine medications in children considering their age. Please check the drug information provided by the manufacturer for use in children before usage.

Considerations for pregnant women
First-generation antihistamine such as chlorpheniramine is the safest choice for treatment of chronic idiopathic urticaria in pregnant women. Considerable usage experience is gained in its long term use without any fetal harm.
For drugs like cetirizine and loratadine there are no  controlled data in human pregnancy and have been assigned to pregnancy category B by the FDA. These drugs are recommended for use during pregnancy when need benefit outweighs risk. They are excreted into human milk. Hence their use is not recommended in nursing mothers.
Like cetrizine, montelukast and zafirlukast have been assigned to pregnancy category B by the FDA.
Cyclosporine and prednisone have been assigned to pregnancy category C by the FDA and are potentially harmful to fetus.

Avoidance of triggers or exacerbating factors

In some cases of chronic urticaria the triggers are identifiable. In such cases avoiding the trigger itself is the treatment. However in idiopathic urticaria the causes are not known. Avoiding the possible causes may bring relief to the patient affected by the idiopathic allergy.

• Avoid tight fitting clothes, shoes and belts.
• Try to keep your surroundings cool.
• Avoid hot or cold baths.
• Avoid stress and tension.
• Do not do strenuous exercise.
• Inform the doctor about your proneness to urticaria when he prescribes medications.
• Avoid possible food triggers.
• Avoid exposure to sun.
• Avoid exposure to cold winds.
• Avoid exposure to germicides, pesticides and detergents.

Avoiding the triggers and proper and complete treatment will help in resolving chronic idiopathic urticaria without any skin scars, blemishes or discolorations.

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Topic of interest:
Types of urticaria - Types of physical urticaria

Reference:
1. Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. 2009 Jun;39(6):777-87. Epub 2009 Apr 22.

Types of urticaria (hives) - Types of physical urticaria

Home > Types of urticaria - Types of physical urticaria

Classification of urticaria types into acute and chronic are accepted worldwide. Arbitrarily, the urticaria lasting less than six weeks is called acute type whereas the one lasting longer than six weeks is considered chronic.

Further, if psychosomatic and physical influences trigger this condition it is called physical urticaria. The conditions are called idiopathic when the causes are not known. Nearly 50% of the occurrences are caused by unknown factors.

Physical urticaria

    These types are very distinct and are induced by exogenous physical stimulus. The source of stimulus can be thermal, mechanical and cholinergic. Ten percent of chronic urticaria are physical urticaria. Considering the types of stimuli, these typs are categorized into sub-groups like dermatographism, delayed-pressure, cholinergic, cold, solar, heat, aquagenic and vibratory urticaria.

    Dermatographism is very common and induced by scratching or firmly stroking the skin. The swollen skin spots may appear immediately and resolve in about 30 minutes. In a normal healthy person though scratching may produce linear reddening without itching, in dermographism, itchy swelling develops. If the skin swelling persists or causes discomfort, taking antihistamines may resolve them.

    Cholinergic or stress type is widespread  and is caused due to rise in the core body temperature. Strenuous exercise and warm or hot bath may trigger the condition. Numerous small welts appear causing itching, tingling and burning sensation. The red spots appear quickly and last up to two hours. It is considered that psychosomatic influences stimulate parasympathetic nervous system leading to release of histamine throughout the body.

    Cold influenced physical urticaria is common in youngsters. On exposure to cold winds, cold water and cold climate, red spots appear on exposed parts like face, neck and hands. There is another hereditary type which may cause red swollen spots all over the body, nine to eighteen hours  after exposure. For persons with this condition, there is a grave danger in swimming in cold waters, as there may be massive release of histamine leading to low blood pressure and shock.

    Delayed-pressure urticaria is a rare physical type and skin swelling occurs in the areas where there is sustained pressure. Usually in this delayed type, swollen spots appear approximately six hours from initial stimulus and may last between eight hours to three days. Belts, straps, tight-fitted clothing and activities giving sustained pressure on the skin can trigger this condition.

    Heat induced urticaria is a rare physical type wherein swollen spots appear on continued application of heat. The spots may appear within two to three minutes of exposure and may last up to one hour.

    Solar or sun induced urticaria is caused on exposure to sun on the exposed skin areas. Though this physical type appears within a few minutes of exposure, it resolves within a few hours from withdrawing the sun exposure. Depending upon the wavelength of light triggering the condition, six different types are known.

    Water (aquagenic) urticaria is triggered on contact with water and the response is not temperature dependent. The skin swelling appears within one to ten minutes after the contact and may last up to two hours. Histamine release is not involved in this condition and there is a opinion that sensitivity of skin to additives in the water may the triggering factor.

    Vibratory urticaria is a rare physical type and develops on contact with vibration. Painful angioedema develops within five minutes after contact with vibration and may last up to one hour.

    Exercise-induced anaphylaxis is a rare physical type causing skin swelling and itchiness, shortage of breath and low blood pressure. The symptoms may appear within thirty minutes from the start of exercise and sometimes may prove fatal. Unlike cholinergic Urticaria, in this type hot bath does not trigger the condition. Hospitalization and treatment with antihistamines, epinephrine and ventilator support may be required.

Drug-induced type of urticaria

    Many drugs have been found to cause allergic reactions like minor skin rashes and urticaria. The most common causes of drug induced allergy are penicillin and related antibiotics like amoxicillin and ampicillin. Other common urticaria inducing drugs are sulfonamides, antiepileptic drugs, antidiabetic drugs, insulin preparations, aspirin, dextroamphetamine and clotrimazole. Some of them can lead to severe physical symptoms like angioedema, severe asthma, anaphylaxis and cardio-respiratory failure.

    Knowing and avoiding the triggering factors and use of appropriate antihistamine medicines can resolve all types of physical urticaria without leaving any skin blemishes, discolorations and scars.

Related topic of interest:
Acute urticaria

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Image:
James Heilman, MD, http://commons.wikimedia.org/wiki/User:Jmh649/CC BY-SA 3.0

References:
1.Marcus Maurer and Jürgen Grabbe, Urticaria: Its History-Based Diagnosis and Etiologically Oriented Treatment, Dtsch Arztebl Int. 2008 June; 105(25): 458–466. PMCID: PMC2696901
2.Barbaud A, [Physical urticaria], Ann Dermatol Venereol. 2003 May;130 Spec No 1:1S16-27, PMID: 12843805

Acute urticaria (hives)

Home > Chronic hives > Acute urticaria

What is acute urticaria?

Acute urticaria (AU) are distinct skin conditions characterized by itchy welt or wheals appearing as flat-topped, round, annular or geographic pale-pink-red papules or plaques typically evanescent, resolving and disappearing within 24 to 48 hours.

In rare cases the AU manifestations last longer. If the weal lasts longer than six weeks it is classified as chronic urticaria (CU). It is found that 20% to 30% of the cases of acute weals recur and some evolve into chronic cases. Au is one of the common medical condition known and its life time prevalence is 10% -25%.

The weals/papules can suddenly appear on any area of skin. Adjoining papules may join together to form larger swollen areas known as plaques. The weals may fade gradually and the skin may become normal in a short time. As some papules fade some fresh papules may also appear. The associated itching and the blotched appearance of the affected skin is very distressing.

In some cases AU is associated with angioedema. Angioedema often causes swelling of eyelids, lips and sometimes tongue. The puffiness may also occur in the face, ears, hands, feet and genitalia. Usually the swellings do not cause itching and are painful. The swelling occurs in the deeper layers of skin. Along with cutaneous manifestations of acute weals some people get extra cutaneous manifestations such as body ache, joint pains and gastrointestinal tract problems. This is probably due to systemic effect of inflammatory mediators released by mast cells present in the skin as well as by the local mast cells.

Causes of acute urticaria

The basic cause of all types of urticaria is activation of cutaneous mast cells and release of histamine and other mediating chemicals of inflammation. Histamine by activating the endothelium and dilating capillary venules causes blood plasma to leak into the interstitial spaces. This causes edema, reddening, warmth, itching and pain.

Possible triggers of Acute urticaria

In children dominating causative factors are viral infections, medication intolerance and food allergies. In adults also acute infections, food allergies and chemical allergies play a triggering part. Other triggers include insect stings, exposure to cold, exposure to sun, contact with chemicals, inhalation of allergens, fish, shellfish, nuts, egg, cow's milk etc.  In half of all the cases, acute urticaria are idiopathic, appearing spontaneously without any known provocation.

Treatment for acute urticaria

As acute urticaria is self-limiting it is treated symptomatically to completely suppress the clinical manifestations. Taking antihistamines eases itching and the condition resolves after some time. Treatment regimen include glucocorticoids or non-sedating antihistamines alone or in combination depending upon the requirement.

Risks involved in acute urticaria

Anaphylaxis causes difficulty in breathing and asphyxiation. When AU is associated with anaphylaxis, it is life-threatening and is a medical emergency. Anaphylaxis is rapid in onset and may cause death. The first-line therapy for anaphylaxis is immediate intramuscular administration of epinephrine and hospitalization for further treatments until recovery.

Related topics of interest:
Chronic urticaria treatment
Types of urticaria

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• Index

References:
1.Marcus Maurer and Jürgen Grabbe, Urticaria: Its History-Based Diagnosis and Etiologically Oriented Treatment, Dtsch Arztebl Int. 2008 June; 105(25): 458–466. PMCID: PMC2696901