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Management of Chronic Urticaria
Identifying Triggers and
Treating Symptoms
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Presentation Facts
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Number of slides: 34
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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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Upon Completion of This Presentation
You Should be Able To
Define the current classification of urticaria and itsimportance on patients quality of life
Understand the new concepts of autoimmune urticaria
Explain the pathophysiology and proficiently diagnose thesymptoms 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 ofHives
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Photo Images ofHives
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Photo Images ofHives
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Photo Images ofHives
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Photo Images ofHives
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Prevalence
25% of the population affected at some time in their lives*
25% of urticaria cases chronic
> 6 weeks duration Over75% 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.N
egro-A
lvarez JM, et al.A
llergol Immunopathol (Madr). 1997;25
:36-5
1.
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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. 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 ofAngioedema 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 to36 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 toinduce sweating
Cold urticaria Holding an ice cube to the forearmremoving, then re-warming will quicklyelicit a hive
Delayed pressure urticaria Weight the skin with a sandbag for ashort period, then observe skin after
three hours
Dermatographism Stroking the back will produce a hive in afew 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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Showers and exercise
Soaps, laundry detergents, fabric softeners
Skin lotions, cosmetics, hair color
Anxiety
Medications (i.e., NSAIDs, oral contraceptives)
Urticaria: What Can Make it Worse?
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Autoimmune Association
35% to 40% of patients have IgG antibody to alphasubunit of IgE
Hashimotos only systemic disorder with commonassociation (possibly reflect underlying autoimmuneprocess for both)
Occasionally manifestation of a connective tissuedisease (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 withouthives to evaluate forHereditory 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- ReceptorAntagonists
Nonsedating anti-H1 improves pruritus and decreasesformation of hives in mild chronic urticaria
Moderate/severe may benefit from higher doses
10 mg cetirizine = 30 mg hydroxyzine with lesssedation
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 ReceptorAntagonists
85/15 ratio of skin H1/H2receptors
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 withantihistamines
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 after4-5 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 severeside 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 thyroidevaluation)
Antihistamines mainstay of therapy (H1
and H2)
Nonsedating at low/high doses effective formild/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