Management of Chronic urticaria

Chronic urticaria (CU) is a disease characterized by the appearance of weals, angioedema or both are present for more than six weeks. Chronic urticaria may be spontaneous or inducible.

Inducible urticaria is also called as physical urticaria & it is classified according to the stimulus that provokes wealing.

• Symptomatic dermographism
• Cold urticaria
• Cholinergic urticaria
• Contact urticaria
• Delayed pressure urticaria
• Solar urticaria
• Heat urticaria
• Vibratory urticaria
• Vibratory angioedema
• Aquagenic urticaria 

Inducible urticaria is more common than spontaneous chronic urticaria.  

In Chronic urticaria, Weals are due to release of chemical mediators from tissue mast cells and circulating basophils. These chemical mediators include histamine, platelet-activating factor and cytokines. The mediators activate sensory nerves and cause dilation of blood vessels and leakage of fluid into surrounding tissues. Bradykinin release causes angioedema.

Clinical features of chronic urticaria are

• Weals that can affect any site of the body and distributed widely
• Weals that can be a few millimetres or several centimetres in diameter.
• Weals can be coloured white or red, with or without a red flare.
• Each weal may last a few minutes or several hours and may change shape before resolving.
• Weals may be round, or form rings, a map-like pattern or giant patches.

Chronic spontaneous urticaria has also been associated with

• Chronic underlying infection, such as Helicobacter pylori, bowel parasites
• Chronic autoimmune diseases, such as systemic lupus erythematosus, thyroid disease, coeliac disease, vitiligo and others
• Lymphoma.

Issued in Public Interest by Oaknet Healthcare

Diagnosis of urticaria 

In Urticaria, the goal of diagnostic measure is to identify the type of urticaria and the underlying cause. Urticaria is usually diagnosed by taking the patient’s history alongside physical examination, with no investigation required to confirm the diagnosis.

The first approach is a exploration of the patient’s history, which covers a variety of topics like time of onset, weekly frequency, duration of wheals, provoking factors, diurnal variation, occurrence in relation to workday or weekends, character and distribution of wheals, associated angioedema, itchiness or pain of wheals, systemic symptoms, personal and family history regarding urticaria and allergy, psychiatric diseases, gastrointestinal problems, induction by physical agents or exercise, use of drugs, observed correlation to food, relation to the menstrual cycle, type of work, hobbies, stress, quality of life and sleep, previous diagnosis, previous treatment and response to treatment, and previous investigations and results. Knowing the patient’s history helps to exclude major comorbid disorders and physical urticaria.     

The second step of diagnosis is a physical examination. A patient can visit a physician without skin lesions or after the lesions have healed. Skin lesion photographs taken by the patient can aid the diagnosis. The wheal is characterised by central swelling of variable size and the surrounding reflex erythema; the wheals will often dissolve and the skin will return to its normal appearance. Small size wheals (1–3 mm) are usually seen in physical urticaria. Urticarial vasculitis lesions are non-blanching and may be resolved with post-inflammatory hyperpigmentation. Angioedema typically appears as nonpruritic, brawny, nonpitting oedema, with neither well- defined margins nor erythema; swelling usually occurs around the eyes and lips and is also found on the hands, feet, and throat.   

Treatment of Urticaria  

The main treatment of all forms of urticaria in adults and children is with an oral second-generation antihistamine like Cetirizine, Loratadine, Fexofenadine, Desloratadine, Levocetirizine, Rupatadine, Bilastine.  

There are other medications also used in treatment of urticaria which include   

• Histamine (H-2) blockers.
• Anti-inflammation medications these include oral corticosteroids, such as prednisone that help lessen swelling, redness and itching. These are generally for short-term control of severe hives or angioedema   
• Tricyclic antidepressant help relieve itching    
• Asthma drugs with antihistamines   
• Omalizumab, a monoclonal antibody direct anti-IgE. It binds to the spot where the IgE would normally bind to its receptor on mast cells. Omalizumab is administered as monthly subcutaneous injections and is indicated for the treatment of chronic idiopathic urticaria in adults and adolescents 12 years of age or older when H₁ antihistamine therapy has failed.       
• Immune-suppressing drugs

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