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Urticaria Patient Management

Because numerous disorders have been associated with the presence of both acute and chronic urticaria (CU), management is contingent primarily on patient history, as well as positive diagnosis of associated conditions. The patient history is of particular importance, as past presentation of symptoms will enable you to categorize the rash as acute, chronic, or recurrent.

Management of CU involves both nonpharmacologic and pharmacologic approaches. Though your strategy used will depend upon the patient’s category of urticaria, the approach is generally two-fold:1,2

  • Avoidance of known triggers (such as nonsteroidal anti-inflammatory drugs, heat, and tight clothing) that may exacerbate chronic urticaria
  • Monotherapy with second generation antihistamine

Well-established clinical guidelines for the management of urticaria can also point you in the direction of the most effective management for your patient:

Patient Education: A Management Strategy Unto Itself

Effective communication, the backbone of patient education, can itself be a management strategy. Be sure to inform patients with urticaria, whether acute or chronic, as well as their families or caregivers that the following factors may contribute to a resurgence of symptoms3,4

  • Recent illness
  • Medication use
  • IV radiocontrast media
  • Foods
  • New perfumes, hair dyes, detergents, lotions, creams, or clothes
  • Exposure to new pets (dander), dust, mold, chemicals, or plants
  • Pregnancy (usually occurs in last trimester and typically resolves spontaneously soon after delivery)
  • Contact with nickel, rubber, latex, industrial chemicals, and nail polish
  • Sun or cold exposure
  • Exercise
  • Alcohol ingestion5

You may advise your patients that exhibit chronic urticaria that repeated symptoms could point to a more serious underlying cause, such as numerous autoimmune diseases, including:6

  • Systemic Lupus Erythematosus
  • Dermatomyositis and polymyositis
  • Mastocytosis
  • Sjögren's Syndrome
  • Thyroid Disease
  • Still Disease
  • Celiac Disease

Follow up, Reevaluation, and Further Testing

In some cases, urticaria may resolve on its own without the need for follow-up or recurring care. However, further evaluation may be needed if your patient’s symptoms persist or worsen. Urticaria that is present for more than 6 weeks could indicate a chronic condition, or that an autoimmune disorder is present.6

As you continue to monitor your patient, be vigilant for not only additional incidences of urticaria, but for additional symptoms that may point to associated diseases, such as:7

  • Systemic lupus erythematosus (SLE)
  • Rheumatoid Arthritis (RA)
  • Autoimmune Thyroid Disease (AITD)
  • Mast Cell Activation Disorder (MCAD)

Subsequent serological testing can help you diagnose these diseases, which have been found to be associated with chronic urticaria.

In selected cases, you may find it necessary or beneficial to consult with or refer your patient to a dermatologist, allergist, immunologist, or rheumatologist. This may especially be true if your patient has recurrent, refractory, severe, or chronic urticaria. Keep in mind that a dermatology referral is strongly recommended if you suspect your patient has urticarial vasculitis.4

Could your patient’s urticaria stem from a more serious underlying cause?

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References

  1. Yadav S, Bajaj AK. Management of Difficult Urticaria. Indian J Dermatol. 2009;54(3):275-279.

  2. Godse KV. Chronic Urticaria and Treatment Options. Indian J Dermatol. 2009;54(4):310-312.

  3. Deacock, SJ. An approach to the patient with urticaria. Clin Exp Immunol. 2008;53(2)151-161.

  4. Wong HK. Uticaria. Medscape. 2017.https://emedicine.medscape.com/article/762917-overview. Accessed December 2017.

  5. Ribeiro F, Sousa N, Carrapatoso I, et al. Urticaria after ingestion of alcoholic beverages. J Investig Allergol Clin Immunol. 2014;24(2):122-123.

  6. Bernstein JA, Lang DM, Khan DA. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014;133(5):1270-1277.

  7. Fraser K, Robertson L, Chronic urticaria and autoimmunity. Skin Therapy Lett. 2013;18(7):5-9.