blood tests are unnecessary for mild ordinary urticaria in patients responding to antihistamines (1)
the choice of investigations should be guided by the clinical presentation (1)
treatment of cause if identified
general measures:
avoidance of triggers if known e.g. overheating, stress, alcohol, drugs
dietary modification may be helpful - avoid foods containing salicylate, preservatives or tatrazine
use of a cooling antipruritic lotion - calamine or 1% menthol in aqueous cream
clear written information sheets for patients
pharmacological measures:
antihistamines:
anti-H1 group of anti-histamines - eg. cetirizine, loratidine, terfenadine, astemizole - have significant anti-itch qualities with minimal sedation
note that terfenadine and astemizole can cause cardiac QT prolongation and tachyarrythmias. These drugs should not be used in combination or with other drugs known to lengthen the QT interval e.g. amiodarone, tricyclic antidepressants. Also there is a theoretical interaction between terfenadine and grapefruit juice
currently there are seven nonsedating H1 antihistamines licensed for the treatment of urticaria in the U.K. These include cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, mizolastine (all taken once daily) and Acrivastine (taken three times a day) (3)
addition of a sedating antihistamine is helpful if sleep is disturbed by symptom
in some cases a combination of H1- and H2 receptor antagonists (e.g. cimetidine) may be used. H2 antagonists reduce vasopermeability and vasodilatation (1)
a H2-antihistamine administered concurrently with an H1-antihistamine may modestly enhance relief of itching and wheal formation in some patients with urticaria refractory to treatment with an H1-antihistamine alone. However the available evidence does not justify the routine addition of H2-antihistamine treatment to H1-antihistamine treatment (2)
although antihistamines are not proven as a teratogenic drug it should be avoided during pregnancy especially during the first trimester (3)
chlorphenamine is the recommended drug in controlling urticaria or pruritus during pregnancy (4)
antileukotrienes
taken together with a H1 antihistamine in poorly controlled urticaria (3)
not useful as a monotherapy
montelukast is the drug of choice (4)
corticosteroids
systemic steroids are not routinely used in the management of chronic urticaria.
however in some cases may be recommended as a short course for non-responders to antihistamines (e.g. prednisolone 40 mg daily for 3-5 days in an adult)(1,3)
systemic steroids may be required in delayed-pressure urticaria and to control urticarial vasculitis when a course of three to four weeks in tapering dose will be required
long-term administration should be avoided in chronic urticaria (3)
epinephrine
intramuscular epinephrine can be used in anaphylaxis and in severe laryngeal angio-oedema (3)
immunomodulating therapy
ciclosporin has been useful in resistant chronic urticaria
plasmaphoresis, intravenous immunoglobulin, and oral tacrolimus may be used in severe resistant autoimmune urticaria (4)
omalizumab is recommended as an option as add-on therapy for treating severe chronic spontaneous urticaria in adults and young people aged 12 years and over (5)
topical corticosteroids and topical antihistamines are not recommended in the management of urticaria (4)
a patient should be referred an immunologist or dermatologist when there is:
urticaria with angio-oedema not involving the airway
food or latex allergy causing severe acute urticaria
chronic persistent urticaria (usually lasting beyond 6 weeks) which is troublesome despite the use of antihistamines and avoidance of known trigger factors
vasculitic urticaria: suspect if lesions are painful and persistent (4)
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