Management of Chronic Urticaria

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Management of Chronic Urticaria

• Identifying Triggers and
• Treating Symptoms

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Presentation Facts

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Acknowledgments

• This is a presentation of the American Academy
  of Family Physicianssupported by an educational
  grant from Aventis Pharmaceuticals
• The AAFP gratefully acknowledges Harold H.
  Hedges, III, M.D.
• andSusan M. Pollart, M.D.for developing the
  content for the AAFP
• andThomas J. Zuber, M.D., M.P.H., MBA, and
  Aventis Pharmaceuticals for providing the photo
  images included in this slide presentation.

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Acknowledgments

• Harold H. Hedges, III, M.D.Private Practice
• Little Rock Family Practice Clinic
• Little Rock, Arkansas
• and
• Susan P. Pollart, M.D.Associate Professor of
  Family MedicineUniversity of Virginia Health
  SystemCharlottesville, Virginia

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Upon Completion of This Presentation You Should
be Able To

• Define the current classification of urticaria
  and its importance on patients quality of life
• Understand the new concepts of autoimmune
  urticaria
• Explain the pathophysiology and proficiently
  diagnose the symptoms associated with urticaria
• Develop appropriate strategies to treat and
  effectively manage the symptoms of urticaria

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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

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Hives Lesions That Are

• Pruritic
• Erythematous
• Roughly circular
• Sometimes confluent

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Photo Images of Hives
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Photo Images of Hives
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Photo Images of Hives
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Photo Images of Hives
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Photo Images of Hives
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Prevalence

• 25 of the population affected at some time in
  their lives
• 25 of urticaria cases chronic
• gt 6 weeks duration
• Over 75 of chronic cases idiopathic
• Affects 0.1 to 3 of population

Strachan DD, et al. Emedicine 2002.
http//www.emedicine.com/DERM/topic443.htm.
Greaves MW. N Engl J Med. 19953321767-1772.
Krishnaswamy G, et al. Postgrad Med.
2001109107-123.
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Remission and Recurrence

• Spontaneous remission rates
• 50 in 3 to 12 months
• 20 in 12 to 36 months
• 20 in 36 to 60 months
• 1.5 in 25 years
• Recurrence rate
• 25 to 40

Negro-Alvarez JM, et al. Allergol Immunopathol
(Madr). 200129129-132. Negro-Alvarez JM, et
al. Allergol Immunopathol (Madr).
19972536-51.
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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

ODonnell BF, et al. Br J Dermatol.
1997136197-201.
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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

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Photo Image of Angioedema of Face
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Urticaria/Angioedema

• Angioedema accompanies uriticaria in about 40 of
  cases
• 40 of patients have hives alone
• 20 of patients have angioedema alone

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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)

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Eliciting Physical UrticariasSelected Procedures
Aquagenic urticaria Apply water
compresses Cholinergic urticaria Have the patient
run up and down stairs to induce sweating Cold
urticaria Holding an ice cube to the forearm
removing, then re-warming will quickly
elicit a hive Delayed pressure urticaria Weight
the skin with a sandbag for a short period,
then observe skin after three
hours Dermatographism Stroking the back will
produce a hive in a few minutes Solar
urticaria Phototest patient (special lamp
needed) Vibratory angioedema Apply a vibratory
lab mixer to the forearm
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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

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Urticaria What Can Make it Worse?

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

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Autoimmune Association

• 35 to 40 of patients have IgG antibody to alpha
  subunit of IgE
• Hashimotos only systemic disorder with common
  association (possibly reflect underlying
  autoimmune process for both)
• Occasionally manifestation of a connective
  tissue disease (cutaneous vasculitis accounts for
  lt 1)

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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 Hashimotos (diseases occur
  in parallel)

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Therapeutic Options

• H1 receptor antagonists
• Combined H1 and H2 receptor antagonists
• Leukotriene antagonists
• Sympathomimetic agents
• Corticosteroids
• Experimental therapies

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Histamine H1- Receptor Antagonists

• Nonsedating anti-H1 improves pruritus and
  decreases formation of hives in mild chronic
  urticaria
• Moderate/severe may benefit from higher doses
• 10 mg cetirizine 30 mg hydroxyzine with less
  sedation
• Mizolastine (not available in US) efficacious and
  non-sedating

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New Generation AntihistaminesRecommended 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
Respective package inserts
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Combined H1-H2 Receptor Antagonists

• 85/15 ratio of skin H1/H2 receptors
• Combination of anti H12 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

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Leukotriene Antagonists

• Zafirlukast and montelukast superior to placebo
  in treatment of chronic urticaria
• Have not been compared to therapy with
  antihistamines
• No additional effect once maximal antihistamine
  effect achieved

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Sympathomimetic Agents

• Oral sympathomimetics (e.g., terbutaline) studied
  to reduce erythema/swelling
• Side effects substantial (insomnia, tachycardia)
• Efficacy low

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Corticosteroids

• Indicated when inadequate response to histamine
  receptor blockers and leukotriene receptor
  antagonists
• Effective but with substantial side effects
• Alternate day therapy if must be used
• One approach start 15-20 mg qod and taper to
  2.5-5mg q three weeks, d/c after 4-5 months

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Experimental Therapies

• Cyclosporine at low doses (2.5-3 mg/kg)
  effective and steroid sparing
• High dose (6 mg/kg) very effective but with
  severe side effects
• Other agents less well studied include
  sulfasalazine, hydroxychloroquine and dapsone, IV
  IgG
• Plasmapheresis for patients with anti-IgE Ab
  effective but impractical for long-term treatment

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Recommendations

• Laboratory workup rarely necessary (except
  thyroid evaluation)
• Antihistamines mainstay of therapy (H1and H2)
• Nonsedating at low/high doses effective for
  mild/moderate disease
• Older, sedating antihistamines more effective for
  severe urticaria and/or angioedema
• LTRAs worth trying
• Minimize systemic corticosteroids (alternate day)

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Thank You
This has been a presentation of the American
Academy of Family Physicians