chronicurticariasinnwell...¡delayed pressure urticaria/angioedema (dpua) swelling occurs 4-6 hours...
TRANSCRIPT
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Elise Sinnwell PA-C
CHRONIC URTICARIA: APPROACH TO EVALUATION AND MANAGEMENT
¡ None
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DISCLOSURES
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¡ Define the differences between acute and chronic urticaria including possible causes
¡ Describe typical clinical manifestations of urticaria and identify features that are concerning for urticarial vasculitis
¡ Describe common triggers for chronic urticaria including identifying patients with physical urticaria syndromes
¡ Identify when targeted lab evaluation or referral for allergy testing is indicated
¡ Describe appropriate stepwise management of chronic urticaria
LEARNING OBJECTIVES
1. Is it urticaria/angioedema?
2. Is it acute or chronic?
3. Consider possible triggers including whether may have physical urticaria
4. Consider dif ferential diagnosis 5. Consider targeted lab evaluation 6. Management
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OUTLINE
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IS IT URTICARIA/ANGIOEDEMA?
¡ Urticaria § Red/pink, raised, pruritic, wheal(s) of variable
shapes (round, oval, serpiginous) § May have central clearing § Blanch with pressure § Individual lesions last <24-48 hours and leave no
residual changes to skin Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 6
IS IT URTICARIA/ANGIOEDEMA?
¡ Angioedema § Swelling of face, tongue, throat, genitalia, extremities
§ Non-pruritic, non-pitting edema § Approximately 40% of patients with urticaria have
accompanying angioedema
§ Angioedema w/o urticaria should prompt considerations of ACEI-induced, hereditary or acquired angioedema
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IS IT URTICARIA/ANGIOEDEMA?
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 8
IS IT URTICARIA/ANGIOEDEMA?
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1. Is it urticaria/angioedema?
2. Is it acute or chronic?
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OUTLINE
¡ Duration<6 weeks ¡ May have identifiable
cause ¡ May be caused by IgE-
mediated response to allergen
Chronic
¡ Duration>6 weeks ¡ Cause is not identified
in majority of cases ¡ Not caused by IgE-
mediated response to allergen (with rare exception)
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IS IT ACUTE VS CHRONIC?
Acute
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
¡ May be caused by § IgE-mediated reactions (food,
hymenoptera, allergen IT) § Medications § Infection
¡ Testing as indicated by history
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ACUTE URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
¡ Cause or associated systemic disorder cannot be identified in majority of cases
¡ Unclear pathogenesis for chronic urticaria
§ Autoimmune theory ¡ Reported with a variety of systemic disorders including
autoimmune disorders, thyroid disorders, malignancy, infection
¡ History and exam findings may dictate whether further
evaluation is needed but extensive work up is not recommended in majority of cases
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CHRONIC URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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1. Is it urticaria/angioedema?
2. Is it acute or chronic?
3. Consider possible triggers including whether may have physical urticaria
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OUTLINE
¡ NSAIDS/ASA ¡ Heat/tight clothing ¡ Stress
¡ Alcohol
¡ Opiates
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TRIGGERS
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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PHYSICAL URTICARIA
¡ Dermatographism ¡ Cholinergic urticaria ¡ Delayed pressure urticaria ¡ Cold urticaria ¡ Solar urticaria ¡ Vibratory urticaria ¡ Aquagenic urticaria
¡ Dermatographism § Most common type of
physical urticaria
§ Simple vs symptomatic § Test: Stroke skin with
firm object (tongue blade)
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PHYSICAL URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Abajian M et al. Physical Urticarias and Cholinergic Urticaria. Immunol Allergy Clin N Am. 2014; 34: 73-88.
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¡ Cholinergic urticaria § “Pinpoint” (1-3 mm)
§ Exercise, hot water, strong emotions, sweating
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PHYSICAL URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Abajian M et al. Physical Urticarias and Cholinergic Urticaria. Immunol Allergy Clin N Am. 2014; 34: 73-88.
¡ Cholinergic urticaria
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PHYSICAL URTICARIA
¡ Delayed pressure urticaria/angioedema (DPUA) § Swelling occurs 4-6 hours after exposure to pressure
§ Carrying heavy bag, sitting on hard surface, standing on feet for long periods
§ Hands, feet, buttock
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PHYSICAL URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Abajian M et al. Physical Urticarias and Cholinergic Urticaria. Immunol Allergy Clin N Am. 2014; 34: 73-88.
¡ Cold urticaria: § Urticaria w/ exposure of skin to cold § Triggers: holding cold drink, lip/pharyngeal
symptoms w/ cold beverage § May trigger systemic reaction (swimming pool)
¡ Solar urticaria § Urticaria develops within 1-3 minutes of sun
exposure to skin
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PHYSICAL URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Abajian M et al. Physical Urticarias and Cholinergic Urticaria. Immunol Allergy Clin N Am. 2014; 34: 73-88.
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¡ Vibratory urticaria/angioedema: § Swelling and pruritus w/in 1-3 minutes of exposure to
vibratory stimulus § Triggers: working with machinery, riding motorcycle
¡ Aquagenic urticaria: § Urticaria develops w/in 30 minutes of skin contact w/
water § Hives are generally 1-3 mm in size
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PHYSICAL URTICARIA
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Abajian M et al. Physical Urticarias and Cholinergic Urticaria. Immunol Allergy Clin N Am. 2014; 34: 73-88.
1. Is it urticaria/angioedema?
2. Is it acute or chronic?
3. Consider possible triggers including whether may have physical urticaria
4. Consider dif ferential diagnosis
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OUTLINE
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Differential diagnosis Features
Cryoglobulinemia Cold induced lesions, purpura, Raynaud’s phenomenon, occurring on extremities
Urticarial vasculitis Lesions lasting >24-48 hours, hyperpigmentation See next slide
Mast cell disorders Urticaria pigmentosa. Episodic flushing, itching, hypotension, GI symptoms
Hypereosinophilic syndrome Total eosinophil count >1500/microL
Schnitzler syndrome Monoclonal gammopathy, fever, non-pruritic urticaria, bone pain
Cryopyrin-mediated periodic syndromes
Familial cold autoinflammtory syndrome Muckle-Wells syndrome
Pruritic urticarial papules and plaques of pregnancy
Urticarial plaques on abdominal striae in third trimester
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Saini SS. Chronic Spontaneous Urticaria: Etiology and Pathogenesis. Immunol Allergy Clin N Am. 2014;; 34: 33-52.
¡ Suspect when lesions last >24-48 hours, leave residual ecchymosis or hyperpigmentation, painful lesions
¡ Requires skin biopsy for diagnosis ¡ May be isolated to the skin or may have systemic involvement
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URTICARIAL VASCULITIS
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Venzor J et al. Urticarial Vasculitis. Clinical Reviews in Allergy and Immunology. 2002; 23: 201-216.
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1. Is it urticaria/angioedema? 2. Is it acute or chronic?
3. Consider possible triggers including whether may have physical urticaria
4. Consider dif ferential diagnosis 5. Consider targeted lab evaluation
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OUTLINE
¡ Majority of cases of chronic urticaria is not associated with systemic disorder or external cause
¡ Evaluation should be limited and targeted based on history, physical exam, ROS
¡ Appropriate limited testing might include: § TSH § ESR/CRP § CBC with differential § LFTs
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TARGETED EVALUATION
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
27 Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
1. Is it urticaria/angioedema?
2. Is it acute or chronic?
3. Consider possible triggers including whether may have physical urticaria
4. Consider dif ferential diagnosis 5. Consider targeted lab evaluation
6. Management
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OUTLINE
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¡ Avoidance of triggers ¡ Education ¡ Medication management
§ Stepwise approach § Alternative therapies
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MANAGEMENT
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 30 Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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H1 SECOND GENERATION ANTIHISTAMINES
¡ Example: loratadine, fexofenadine, cetirizine ¡ May begin at once or twice daily dosing ¡ Can be increased to 4 times standard dose (i.e., cetirizine 20
mg BID)
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. Staevska M, et al. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult-to- treat urticaria. J Allergy Clin Immunol. 2010;125: 676-82.
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H1 FIRST GENERATION ANTIHISTAMINES
¡ Examples: diphenhydramine, hydroxyzine ¡ Side effects: drowsiness, anticholinergic side effects ¡ Can be tried initially with daily nighttime dosing
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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H2 ANTAGONISTS
¡ Examples: ranitidine, cimetidine, famotidine ¡ Consider trial during step 2 therapy
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 34
LEUKOTRIENE RECEPTOR ANTAGONISTS
¡ Examples: montelukast, zafirlukast ¡ Consider trial during step 2 therapy
De Silva NL et al. Leukotriene receptor antagonists for chronic urticaria: a systemic review. Allergy, Asthma & Clinical Immunology. 2014; 10 (24): 1-6. Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
¡ Dapsone ¡ Sulfasalazine ¡ Hydroxychloroquine ¡ Cyclosporine ¡ Omalizumab (anti-IgE)
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ALTERNATIVE THERAPIES
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 36 Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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¡ Short term use may be considered ¡ Consider side effects (weight gain, hyperglycemia,
osteoporosis, adrenal suppression, gastritis, immunosuppression, etc)
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STEROIDS?
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014. 38
Step up Step down
Bernstein JA et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
¡ Urticaria typically presents with: § red, raised wheal(s) of variable sizes and shapes, individual lesions
last <24-48 hours and leave no residual skin changes
¡ Acute urticaria:
§ has duration <6 weeks and may have identifiable cause
¡ Chronic urticaria: § has duration >6 weeks and cause or associated systemic disorder is
not identified in majority of cases
¡ Some patients with chronic urticaria have nonspecific triggers: § NSAIDS, tight clothing/heat, alcohol, opiates, stress
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TAKE HOME POINTS
¡ Physical urticaria: § Is a subgroup of chronic urticaria in which primary trigger for
urticaria/angioedema is environmental/external stimulus
¡ Evaluation of patient with chronic urticaria:
§ Should be limited § If any testing is done, should be targeted based on history and exam
¡ Management of patient with chronic urticaria: § Includes avoidance, education/reassurance and medication
management
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TAKE HOME POINTS
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¡ 25 yo F presents with 3 month hx of hives that occur daily
¡ Describes as “very itchy spots
that come and go” ¡ Eyelid will swell shut sometimes ¡ Concerned about allergy and
has restricted her diet and avoided going outdoors
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CASE
¡ Hives seem to worsen after she takes ibuprofen
¡ Exam is notable only for
+dermatographism ¡ ROS completely negative ¡ Recent normal TSH,
ESR/CRP, CBC with differential, LFTs
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CASE
¡ Education/reassurance ¡ Recommend avoidance of
NSAIDs ¡ Start cetirizine 10 mg BID
¡ Follow up in 4 weeks
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CASE
Bernstein et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
¡ At follow up, hives improved but still having some during day and very itchy at night
¡ Increase cetirizine to 20 mg BID and add hydroxyzine 25 mg QHS
¡ Return visit in 4-6 weeks ¡ Hives much improved, elect to
continue regimen for next 3 months
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CASE
Bernstein et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol.2014.
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Questions?