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Management of Chronic Urticaria

Identifying Triggers and


Treating Symptoms

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Acknowledgments
This is a presentation of the
American Academy of Family Physicians
supported by an educational grant from
Aventis Pharmaceuticals

The AAFP gratefully acknowledges


Harold H. Hedges, III, M.D.
and
Susan M. Pollart, M.D.
for developing the content for the AAFP
and
Thomas 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 Medicine
University of Virginia Health System
Charlottesville, 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 patient’s 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†
– > 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. 1995;332:1767-1772.
‡ Krishnaswamy G, et al. Postgrad Med. 2001;109:107-123.

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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). 2001;29:129-132.


Negro-Alvarez JM, et al. Allergol Immunopathol (Madr). 1997;25:36-51.
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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

O’Donnell BF, et al. Br J Dermatol. 1997;136:197-201.

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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 Urticarias
Selected 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
• Hashimoto’s only systemic disorder with common
association (possibly reflect underlying autoimmune
process for both)
• Occasionally manifestation of a connective tissue
disease (cutaneous vasculitis accounts for < 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 Hashimoto’s (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 Antihistamines
Recommended 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 H1&2 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 (H 1and 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

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