Membership Presentation Urticaria

8/8/2019 Membership Presentation Urticaria

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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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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



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

Membership Presentation Urticaria

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