Urticaria medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Urticaria}}
{{Urticaria}}
{{CMG}}
{{CMG}} ; {{AE}} {{Anahita}}


==Overview==
==Overview==
Urticarias can be very difficult to treat. There are no guaranteed treatments or means of controlling attacks, and some sub-populations are treatment resistant, with medications spontaneously losing their effectiveness and requiring new medications to control attacks.  It can be difficult to determine appropriate medications since some such as [[loratadine]] require a day or two to build up to effective levels, and since the condition is intermittent and outbreaks typically clear up without any treatment.
[[Therapy|Medical treatment]] is required for [[patients]] who are annoyed by [[urticaria|wheals]] appearance and [[itch|pruritus]]. First line [[treatment]] is [[H1 antihistamine]] [[medications]], such as [[diphenhydramine]], [[hydroxyzine]], [[cetirizine]] and other [[H1 antihistamine]]. Some [[patients]] might require high [[doses]] of [[antihistamines]] for a complete control of their [[symptoms]], but fortunately it's high [[dose|doses]] are tolerated by most [[patients]]. If [[antihistamines]] as the first line [[treatment]] didn't successfully controlled the [[symptoms]], [[omalizumab]] and [[cyclosporine]] should be tried as the second line [[treatment]]. [[Omalizumab]] has been effective in different sub-types of [[urticaria]], such as [[urticaria|solar urticaria]], [[urticaria|cold urticaria]], [[urticaria|cholinergic urticaria]], [[urticaria|urticarial vasculitis]] and [[urticaria|symptomatic dermatographic urticaria]]. There are some other alternatives if the aforementioned [[medications]] didn't help, alternatives such as [[dapsone]], [[hydroxychloroquine]], [[sulfasalazine]], [[colchicine]], [[methotrexate]], [[gamma globulin|intravenous gamma globulin]], [[plasmapheresis]], [[corticosteroids]], [[H2 antagonists]] and [[Leukotriene|leukotriene antagonists]]. Some studies recommended specific alternative [[treatment]] for each subtypes of [[urticaria]].  
 
Most treatment plans for urticaria involve being aware of one's triggers, but this can be difficult since there are several different forms of urticaria and people often exhibit more than one type. Also, since symptoms are often [[idiopathic]] there might not be any clear trigger. If one's triggers can be identified then outbreaks can often be managed by limiting one's exposure to these situations.


==Medical Therapy==
==Medical Therapy==
===Histamine Antagonists===
===Histamine Antagonists===
*[[Antihistamines]], such as [[diphenhydramine]], [[hydroxyzine]], [[cetirizine]] and other [[H1 antihistamine|H<sub>1</sub> receptor antagonists]] are recommended as the first line [[treatment]] for [[urticaria]]. These are taken on a regular basis for their protective effect, lessening or halting attacks.<ref name="pmid18094952">{{cite journal |author=Greaves MW, Tan KT|title=Chronic Urticaria: Recent Advances |journal=Clin Rev Allergy Immunol |volume=33 |issue=1-2 |pages=134–143 |year=2007|pmid=18094952 |doi=10.1007/s12016-007-0038-3}}</ref>  
 
*[[Antihistamines]], such as [[diphenhydramine]], [[hydroxyzine]], [[cetirizine]] and other [[H1 antihistamine|H1 antihistamines]] are recommended as the first line [[treatment]] for [[urticaria]]. These are taken on a regular basis for their protective effect, lessening or halting attacks.<ref name="pmid18094952">{{cite journal |author=Greaves MW, Tan KT|title=Chronic Urticaria: Recent Advances |journal=Clin Rev Allergy Immunol |volume=33 |issue=1-2 |pages=134–143 |year=2007|pmid=18094952 |doi=10.1007/s12016-007-0038-3}}</ref>
*[[Antihistamines]] are effective on high [[dosage|doses]] and most of the time are tolerated by [[patients]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>
*[[Antihistamines]] are effective on high [[dosage|doses]] and most of the time are tolerated by [[patients]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>
*Furthermore [[H₂-receptor antagonists]], such as [[cimetidine]] and [[ranitidine]], may help to control [[symptoms]] either [[Prophylaxis|prophylactically]] or by relieving [[symptoms]] during an attack.<ref name="pmid11702618">{{cite journal|author=Lee EE, Maibach HI |title=Treatment of urticaria. An evidence-based evaluation of antihistamines |journal=Am J Clin Dermatol|volume=2 |issue=1 |pages=27–32 |year=2001 |pmid=11702618 |doi=}}</ref>  
*Furthermore [[H2 antihistamine|H2 antagonists]], such as [[cimetidine]] and [[ranitidine]], may help to control [[symptoms]] either [[Prophylaxis|prophylactically]] or by relieving [[symptoms]] during an attack.<ref name="pmid11702618">{{cite journal|author=Lee EE, Maibach HI |title=Treatment of urticaria. An evidence-based evaluation of antihistamines |journal=Am J Clin Dermatol|volume=2 |issue=1 |pages=27–32 |year=2001 |pmid=11702618 |doi=}}</ref>
*When [[H₂-receptor antagonists]] are taken in combination with [[H1 antihistamines]], a synergistic effect is expected, which is more effective than either [[treatment]] alone.  
*When [[H2 antihistamine|H2 antagonists]] are taken in combination with [[H1 antihistamine|H1 antihistamines]], a synergistic effect is expected, which may be more effective than either [[treatment]] alone in some cases.
*The use of [[ranitidine]] (or other [[H₂-receptor antagonists]]) for urticaria is considered an off-label use, since these [[drugs]] are primarily used for the [[treatment]] of [[peptic ulcer]] [[disease]] and [[gastroesophageal reflux]] [[disease]].
*The use of [[ranitidine]] (or other [[H2 antihistamine|H2 antagonists]]) for [[urticaria]] is considered an off-label use, since these [[drugs]] are primarily used for the [[treatment]] of [[peptic ulcer]] [[disease]] and [[gastroesophageal reflux]] [[disease]].
*If the [[disease]] doesn't response to [[antihistamines]], second line [[treatments]] are recommended.
*If the [[disease]] doesn't response to [[antihistamines]], second line [[treatments]] are recommended.


===Omalizumab===
===Omalizumab===
*[[Omalizumab]] is a [[monoclonal antibody]] against [[immunoglobulin E]] which is a good option for most [[patients]] with [[urticaria]] (effective in more than 80% of cases).<ref name="pmid27286500">{{cite journal| author=Giménez-Arnau AM, Toubi E, Marsland AM, Maurer M| title=Clinical management of urticaria using omalizumab: the first licensed biological therapy available for chronic spontaneous urticaria. | journal=J Eur Acad Dermatol Venereol | year= 2016 | volume= 30 Suppl 5 | issue=  | pages= 25-32 | pmid=27286500 | doi=10.1111/jdv.13697 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27286500  }} </ref><ref name="pmid31180381">{{cite journal| author=Kayiran MA, Akdeniz N| title=Diagnosis and treatment of urticaria in primary care. | journal=North Clin Istanb | year= 2019 | volume= 6 | issue= 1 | pages= 93-99 | pmid=31180381 | doi=10.14744/nci.2018.75010 | pmc=6526977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31180381  }} </ref>
*[[Omalizumab]] is a [[monoclonal antibody]] against [[immunoglobulin E]] which is a good option for most [[patients]] with [[urticaria]] (effective in more than 80% of cases).<ref name="pmid27286500">{{cite journal| author=Giménez-Arnau AM, Toubi E, Marsland AM, Maurer M| title=Clinical management of urticaria using omalizumab: the first licensed biological therapy available for chronic spontaneous urticaria. | journal=J Eur Acad Dermatol Venereol | year= 2016 | volume= 30 Suppl 5 | issue=  | pages= 25-32 | pmid=27286500 | doi=10.1111/jdv.13697 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27286500  }} </ref><ref name="pmid31180381">{{cite journal| author=Kayiran MA, Akdeniz N| title=Diagnosis and treatment of urticaria in primary care. | journal=North Clin Istanb | year= 2019 | volume= 6 | issue= 1 | pages= 93-99 | pmid=31180381 | doi=10.14744/nci.2018.75010 | pmc=6526977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31180381  }} </ref>
*It lessens the function of [[mast cells]] and helps [[Eosinophil granulocyte|eosinophil]] [[apoptosis]]. It also decreases [[cytokine]] release from [[Basophil granulocyte|basophils]].  
*It lessens the function of [[mast cells]] and helps [[Eosinophil granulocyte|eosinophil]] [[apoptosis]]. It also decreases [[cytokine]] release from [[Basophil granulocyte|basophils]].
*Nevertheless high price of this [[medication]] is considered a drawback that decreases it's use.  
*Nevertheless high price of this [[medication]] is considered a drawback that decreases it's use.
*It is used [[Subcutaneous tissue|subcutaneously]] and has been effective in different sub-types of [[urticaria]], such as [[urticaria|solar urticaria]], [[urticaria|cold urticaria]], [[urticaria|cholinergic urticaria]], [[urticaria|urticarial vasculitis]] and [[urticaria|symptomatic dermatographic]].
*It is used [[Subcutaneous tissue|subcutaneously]] and has been effective in different sub-types of [[urticaria]], such as [[urticaria|solar urticaria]], [[urticaria|cold urticaria]], [[urticaria|cholinergic urticaria]], [[urticaria|urticarial vasculitis]] and [[urticaria|symptomatic dermatographic]].


===Cyclosporine===
===Cyclosporine===
*[[Cyclosporine|Cyclosporine A]] has been effective in some cases of [[urticaria]] by it's direct effect on liberation of the [[mast cell]] mediators, nevertheless due to it's high cost it is usually considered as an alternate [[treatment]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref><ref name="pmid1373749">{{cite journal| author=Stellato C, de Paulis A, Ciccarelli A, Cirillo R, Patella V, Casolaro V | display-authors=etal| title=Anti-inflammatory effect of cyclosporin A on human skin mast cells. | journal=J Invest Dermatol | year= 1992 | volume= 98 | issue= 5 | pages= 800-4 | pmid=1373749 | doi=10.1111/1523-1747.ep12499960 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1373749  }} </ref>
*[[Cyclosporine|Cyclosporine A]] has been effective in some cases of [[urticaria]] by it's direct effect on liberation of the [[mast cell]] mediators, nevertheless due to it's high cost it is usually considered as an alternate [[treatment]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref><ref name="pmid1373749">{{cite journal| author=Stellato C, de Paulis A, Ciccarelli A, Cirillo R, Patella V, Casolaro V | display-authors=etal| title=Anti-inflammatory effect of cyclosporin A on human skin mast cells. | journal=J Invest Dermatol | year= 1992 | volume= 98 | issue= 5 | pages= 800-4 | pmid=1373749 | doi=10.1111/1523-1747.ep12499960 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1373749  }} </ref>
*[[Cyclosporine]] has been related to longer remission in long term, compared to [[corticosteroids]].  
*[[Cyclosporine]] has been related to longer remission in long term, compared to [[corticosteroids]].
*Based on numerous studies [[cyclosporine]] is 64%-95% effective in [[patients]] with [[urticaria]].<ref name="pmid17010756">{{cite journal| author=Vena GA, Cassano N, Colombo D, Peruzzi E, Pigatto P, Neo-I-30 Study Group| title=Cyclosporine in chronic idiopathic urticaria: a double-blind, randomized, placebo-controlled trial. | journal=J Am Acad Dermatol | year= 2006 | volume= 55 | issue= 4 | pages= 705-9 | pmid=17010756 | doi=10.1016/j.jaad.2006.04.078 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17010756  }} </ref>  
*Based on numerous studies [[cyclosporine]] is 64%-95% effective in [[patients]] with [[urticaria]].<ref name="pmid17010756">{{cite journal| author=Vena GA, Cassano N, Colombo D, Peruzzi E, Pigatto P, Neo-I-30 Study Group| title=Cyclosporine in chronic idiopathic urticaria: a double-blind, randomized, placebo-controlled trial. | journal=J Am Acad Dermatol | year= 2006 | volume= 55 | issue= 4 | pages= 705-9 | pmid=17010756 | doi=10.1016/j.jaad.2006.04.078 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17010756  }} </ref>
*Due to it's [[Adverse effect (medicine)|side effects]] in long period of use, it is usually reserved for [[patients]] resistant to high [[dose|doses]] of [[antihistamine]] and [[omalizumab]].
*Due to it's [[Adverse effect (medicine)|side effects]] in long period of use, it is usually reserved for [[patients]] resistant to high [[dose|doses]] of [[antihistamine]] and [[omalizumab]].


===Corticosteroids===
===Corticosteroids===
*An [[mouth|oral]] [[corticosteroid]], such as [[prednisone]] can sometimes be prescribed. In a [[randomized controlled trial]] done on adult who had [[urticaria]] with a duration less than 24 hours, a comparison between [[prednisone]] plus [[levocetirizine]] and [[levocetirizine]] alone, yielded 62% and 72% rates of resolution within two days, respectively.<ref name="pmid28476259">{{cite journal| author=Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S| title=Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. | journal=Ann Emerg Med | year= 2017 | volume= | issue= | pages= | pmid=28476259 | doi=10.1016/j.annemergmed.2017.03.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28476259 }} </ref>
*An [[mouth|oral]] [[corticosteroid]], such as [[prednisone]] can sometimes be prescribed. In a [[randomized controlled trial]] done on adult who had [[urticaria]] with a duration less than 24 hours, a comparison between [[prednisone]] plus [[levocetirizine]] and [[levocetirizine]] alone, yielded 62% and 72% rates of resolution within two days, respectively.<ref name="pmid28476259">{{cite journal| author=Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S| title=Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial. | journal=Ann Emerg Med | year= 2017 | volume= | issue= | pages= | pmid=28476259 | doi=10.1016/j.annemergmed.2017.03.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28476259 }} </ref>
*Long term [[treatment]] must be avoided, due to high rates of [[Adverse effect (medicine)|adverse effects]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>
*Long term [[treatment]] must be avoided, due to high rates of [[Adverse effect (medicine)|adverse effects]].<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>


===Others===
===Others===
*[[Beta blockers]], such as [[propranolol]], have been effective in [[treatment]] of [[urticaria|adrenergic urticaria]].<ref name="pmid2865515">{{cite journal| author=Shelley WB, Shelley ED| title=Adrenergic urticaria: a new form of stress-induced hives. | journal=Lancet | year= 1985 | volume= 2 | issue= 8463 | pages= 1031-3 | pmid=2865515 | doi=10.1016/s0140-6736(85)90905-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2865515  }} </ref>
*[[Beta blockers]], such as [[propranolol]], have been effective in [[treatment]] of [[urticaria|adrenergic urticaria]].<ref name="pmid2865515">{{cite journal| author=Shelley WB, Shelley ED| title=Adrenergic urticaria: a new form of stress-induced hives. | journal=Lancet | year= 1985 | volume= 2 | issue= 8463 | pages= 1031-3 | pmid=2865515 | doi=10.1016/s0140-6736(85)90905-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2865515  }} </ref>
*In simultaneous [[Mast cell tumor|mastocytosis]], [[PUVA]] showed to be effective due to it's effect on [[mast cell]] reduction.<ref name="pmid2425755">{{cite journal| author=Olafsson JH, Larkö O, Roupe G, Granerus G, Bengtsson U| title=Treatment of chronic urticaria with PUVA or UVA plus placebo: a double-blind study. | journal=Arch Dermatol Res | year= 1986 | volume= 278 | issue= 3 | pages= 228-31 | pmid=2425755 | doi=10.1007/BF00412929 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2425755  }} </ref><ref name="pmid10764986">{{cite journal| author=Horio T| title=Indications and action mechanisms of phototherapy. | journal=J Dermatol Sci | year= 2000 | volume= 23 Suppl 1 | issue=  | pages= S17-21 | pmid=10764986 | doi=10.1016/s0923-1811(99)00069-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10764986  }} </ref><ref name="pmid9267734">{{cite journal| author=Godt O, Proksch E, Streit V, Christophers E| title=Short- and long-term effectiveness of oral and bath PUVA therapy in urticaria pigmentosa and systemic mastocytosis. | journal=Dermatology | year= 1997 | volume= 195 | issue= 1 | pages= 35-9 | pmid=9267734 | doi=10.1159/000245681 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9267734  }} </ref>  
*In simultaneous [[Mast cell tumor|mastocytosis]], [[PUVA]] showed to be effective due to it's effect on [[mast cell]] reduction.<ref name="pmid2425755">{{cite journal| author=Olafsson JH, Larkö O, Roupe G, Granerus G, Bengtsson U| title=Treatment of chronic urticaria with PUVA or UVA plus placebo: a double-blind study. | journal=Arch Dermatol Res | year= 1986 | volume= 278 | issue= 3 | pages= 228-31 | pmid=2425755 | doi=10.1007/BF00412929 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2425755  }} </ref><ref name="pmid10764986">{{cite journal| author=Horio T| title=Indications and action mechanisms of phototherapy. | journal=J Dermatol Sci | year= 2000 | volume= 23 Suppl 1 | issue=  | pages= S17-21 | pmid=10764986 | doi=10.1016/s0923-1811(99)00069-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10764986  }} </ref><ref name="pmid9267734">{{cite journal| author=Godt O, Proksch E, Streit V, Christophers E| title=Short- and long-term effectiveness of oral and bath PUVA therapy in urticaria pigmentosa and systemic mastocytosis. | journal=Dermatology | year= 1997 | volume= 195 | issue= 1 | pages= 35-9 | pmid=9267734 | doi=10.1159/000245681 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9267734  }} </ref>
*[[Tricyclic antidepressants]] such as [[doxepin]], also are often potent [[H1 antihistamine|H<sub>1</sub>]] and [[H2 antihistamine|H<sub>2</sub> antagonists]] and may have a role in [[therapy]], although their [[Adverse effect (medicine)|side effects]] usually limit their use.
*[[Tricyclic antidepressants]] such as [[doxepin]], which act as a potent [[H1 antihistamine|H<sub>1</sub>]] and [[H2 antihistamine|H<sub>2</sub> antagonists]] and may have a role in [[therapy]], although their [[Adverse effect (medicine)|side effects]] usually limit their use.
*As of 2008 an Australian company is performing [[clinical trials]] with an [[Analog (chemistry)|analogue]] of alpha-[[melanocyte-stimulating hormone]] called [[melanotan]] ([[melanotan|CUV1647]]) for the [[treatment]] of [[urticaria|solar urticaria]], which is a type of [[urticaria]] that develops in response to exposure to specific wavelengths of light.<ref>{{cite web | url =http://www.emedicine.com/derm/topic448.htm | title = Urticaria, Solar | accessdate = 2007-12-26 | date =2007-03-29 | last = Baron |first = ED | coauthors = Taylor, CR | publisher = [[WebMD]] }}</ref><ref name="Australian_Life_Scientist">{{Cite web | url =http://www.biotechnews.com.au/index.php/id;444900667 | title = Tackling skin cancer in organ transplant patients | accessdate = 2007-12-24 | publisher=Australian Life Scientist | date = 2007-04-13 | last = McDonald | first = Kate }}</ref>
*An Australian company performed a [[clinical trials]] with an [[Analog (chemistry)|analogue]] of alpha-[[melanocyte-stimulating hormone]] called [[melanotan]] ([[melanotan|CUV1647]]) for the [[treatment]] of [[urticaria|solar urticaria]].<ref>{{cite web | url =http://www.emedicine.com/derm/topic448.htm | title = Urticaria, Solar | accessdate = 2007-12-26 | date =2007-03-29 | last = Baron |first = ED | coauthors = Taylor, CR | publisher = [[WebMD]] }}</ref><ref name="Australian_Life_Scientist">{{Cite web | url =http://www.biotechnews.com.au/index.php/id;444900667 | title = Tackling skin cancer in organ transplant patients | accessdate = 2007-12-24 | publisher=Australian Life Scientist | date = 2007-04-13 | last = McDonald | first = Kate }}</ref>
 
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The following table is a summary of first and second line [[urticaria]] [[treatments]] and other alternatives:<ref name="pmid28913986">{{cite journal| author=Kaplan AP| title=Chronic Spontaneous Urticaria: Pathogenesis and Treatment Considerations. | journal=Allergy Asthma Immunol Res | year= 2017 | volume= 9 | issue= 6 | pages= 477-482 | pmid=28913986 | doi=10.4168/aair.2017.9.6.477 | pmc=5603475 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28913986  }} </ref>
The following table is a summary of first and second line [[urticaria]] [[treatments]] and other alternatives:<ref name="pmid28913986">{{cite journal| author=Kaplan AP| title=Chronic Spontaneous Urticaria: Pathogenesis and Treatment Considerations. | journal=Allergy Asthma Immunol Res | year= 2017 | volume= 9 | issue= 6 | pages= 477-482 | pmid=28913986 | doi=10.4168/aair.2017.9.6.477 | pmc=5603475 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28913986  }} </ref>
{| border="3"
{| border="3"
! First line [[treatment]] !! Second line [[treatment]] !! third line [[treatment]] !! fourth line [[treatment]]
!First line [[treatment]]!!Second line [[treatment]]!!Third line [[treatment]]!!Fourth line [[treatment]]
|-
|-
! [[Antihistamines]]
![[Antihistamines]]
| [[Omalizumab]] <br> [[Cyclosporine]] || [[Dapsone]] <br> [[Hydroxychloroquine]] <br> [[Sulfasalazine]] <br> [[Colchicine]] <br> [[Methotrexate]] <br> [[Gamma globulin|Intravenous gamma globulin]] <br> [[Plasmapheresis]] || [[Corticosteroid]] <br> [[H2 antagonist]] <br> [[Leukotriene|Leukotriene antagonists]]
|[[Omalizumab]] <br>[[Cyclosporine]]||[[Dapsone]] <br>[[Hydroxychloroquine]] <br>[[Sulfasalazine]] <br>[[Colchicine]] <br>[[Methotrexate]] <br>[[Gamma globulin|Intravenous gamma globulin]] <br>[[Plasmapheresis]]||[[Corticosteroid]] <br>[[H2 antagonist]] <br>[[Leukotriene|Leukotriene antagonists]]
|}
|}
<br>
<br>
The following table is a summary of recommended [[treatment]] in different types of [[urticaria]]:<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>
The following table is a summary of recommended [[treatment]] in different types of [[urticaria]]:<ref name="pmid14616095">{{cite journal| author=Zuberbier T| title=Urticaria. | journal=Allergy | year= 2003 | volume= 58 | issue= 12 | pages= 1224-34 | pmid=14616095 | doi=10.1046/j.1398-9995.2003.00327.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14616095  }} </ref>
{| border="3"
{| border="3"
! Types of [[urticaria]] !! Standard [[treatment]] !! Alternate [[treatment]]
!Types of [[urticaria]]!!Standard [[treatment]]!!Alternate [[treatment]]
|-
|-
! [[urticaria|Acute urticaria]]
![[urticaria|Acute urticaria]]
| [[H1 antihistamines]] ([[sedation|nonsedative]]) || [[Corticosteroid]] (Initiate 50 mg per day of [[prednisolone]] and continue for 3 days)
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||
* [[Corticosteroid]] (Initiate 50 mg per day of [[prednisolone]] and continue for 3 days)
|-
|-
! [[Chronic urticaria]]
![[Chronic urticaria]]
|[[H1 antihistamines]] ([[sedation|nonsedative]])|| <br>  
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||<br>  
*[[H1 antihistamine|H<sub>1</sub>]] and [[H2 antihistamine|H<sub>2</sub> antagonists]]
 
*[[H1 antihistamine|H1 antihistamines]] and [[H2 antihistamine|H<sub>2</sub> antagonists]]
*[[Pentoxifylline]] plus [[dapsone]]
*[[Pentoxifylline]] plus [[dapsone]]
*[[Doxepin]]
*[[Doxepin]]
*[[Danazol]]
*[[Danazol]]
*[[Montelukast|Leukotriene antagonists]], such as [[montekulast]]
*[[Montelukast|Leukotriene antagonists]], such as [[montelukast]]
*[[Corticosteroids]]
*[[Corticosteroids]]
*[[Cyclosporine|Cyclosporin A]]
*[[Cyclosporine|Cyclosporin A]]
Line 69: Line 75:
*[[Immunoglobulins]]
*[[Immunoglobulins]]
|-
|-
! [[urticaria|Dermographic urticaria]]
![[urticaria|Dermographic urticaria]]
| [[H1 antihistamines]] ([[sedation|nonsedative]]) ||         -
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||-
|-
|-
! [[urticaria|Delayed pressure urticaria]]
![[urticaria|Delayed pressure urticaria]]
| [[H1 antihistamines]] ([[sedation|nonsedative]]) || <br>
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||<br>
*[[Corticosteroid]]  
 
*[[Montelukast|Leukotriene antagonists]], such as [[montekulast]]
*[[Corticosteroid]]
*[[Montelukast|Leukotriene antagonists]], such as [[montelukast]]
|-
|-
! [[urticaria|Cold urticaria]]
![[urticaria|Cold urticaria]]
| [[H1 antihistamines]] ([[sedation|nonsedative]]) || <br>
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||<br>
 
*Physical tolerance induction by cold bath
*Physical tolerance induction by cold bath
*[[Montelukast|Leukotriene antagonists]]
*[[Montelukast|Leukotriene antagonists]]
*[[Doxycyline]]
*[[Doxycycline]]
*[[Penicillin]]
*[[Penicillin]]
|-
|-
! [[urticaria|Solar urticaria]]
![[urticaria|Solar urticaria]]
| Physical tolerance induction by UV light || [[H1 antihistamines]] ([[sedation|nonsedative]])
|Physical tolerance induction by [[UV light]]||
* [[H1 antihistamine|H1 antihistamines]] (nonsedative)
|-
|-
! [[urticaria|Cholinergic urticaria]]
![[urticaria|Cholinergic urticaria]]
| [[H1 antihistamines]] ([[sedation|nonsedative]]) || [[Danazol ]]
|[[H1 antihistamine|H1 antihistamines]] ([[sedation|nonsedative]])||
* [[Danazol ]]
|}
|}


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{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Allergology]]
[[Category:Allergology]]
[[Category:Immunology]]
[[Category:Immunology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Disease]]

Latest revision as of 15:21, 9 February 2021

Urticaria Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Overview

Medical treatment is required for patients who are annoyed by wheals appearance and pruritus. First line treatment is H1 antihistamine medications, such as diphenhydramine, hydroxyzine, cetirizine and other H1 antihistamine. Some patients might require high doses of antihistamines for a complete control of their symptoms, but fortunately it's high doses are tolerated by most patients. If antihistamines as the first line treatment didn't successfully controlled the symptoms, omalizumab and cyclosporine should be tried as the second line treatment. Omalizumab has been effective in different sub-types of urticaria, such as solar urticaria, cold urticaria, cholinergic urticaria, urticarial vasculitis and symptomatic dermatographic urticaria. There are some other alternatives if the aforementioned medications didn't help, alternatives such as dapsone, hydroxychloroquine, sulfasalazine, colchicine, methotrexate, intravenous gamma globulin, plasmapheresis, corticosteroids, H2 antagonists and leukotriene antagonists. Some studies recommended specific alternative treatment for each subtypes of urticaria.

Medical Therapy

Histamine Antagonists

Omalizumab

Cyclosporine

Corticosteroids

Others


The following table is a summary of first and second line urticaria treatments and other alternatives:[15]

First line treatment Second line treatment Third line treatment Fourth line treatment
Antihistamines Omalizumab
Cyclosporine		 Dapsone
Hydroxychloroquine
Sulfasalazine
Colchicine
Methotrexate
Intravenous gamma globulin
Plasmapheresis		 Corticosteroid
H2 antagonist
Leukotriene antagonists


The following table is a summary of recommended treatment in different types of urticaria:[2]

Types of urticaria Standard treatment Alternate treatment
Acute urticaria H1 antihistamines (nonsedative)
Chronic urticaria H1 antihistamines (nonsedative)
Dermographic urticaria H1 antihistamines (nonsedative) -
Delayed pressure urticaria H1 antihistamines (nonsedative)
Cold urticaria H1 antihistamines (nonsedative)
Solar urticaria Physical tolerance induction by UV light
Cholinergic urticaria H1 antihistamines (nonsedative)

Contraindicated medications

Urticaria is considered an absolute contraindication to the use of the following medications:

References

  1. ↑ Greaves MW, Tan KT (2007). "Chronic Urticaria: Recent Advances". Clin Rev Allergy Immunol. 33 (1–2): 134–143. doi:10.1007/s12016-007-0038-3. PMID 18094952.
  2. ↑ 2.0 2.1 2.2 2.3 Zuberbier T (2003). "Urticaria". Allergy. 58 (12): 1224–34. doi:10.1046/j.1398-9995.2003.00327.x. PMID 14616095.
  3. ↑ Lee EE, Maibach HI (2001). "Treatment of urticaria. An evidence-based evaluation of antihistamines". Am J Clin Dermatol. 2 (1): 27–32. PMID 11702618.
  4. ↑ Giménez-Arnau AM, Toubi E, Marsland AM, Maurer M (2016). "Clinical management of urticaria using omalizumab: the first licensed biological therapy available for chronic spontaneous urticaria". J Eur Acad Dermatol Venereol. 30 Suppl 5: 25–32. doi:10.1111/jdv.13697. PMID 27286500.
  5. ↑ Kayiran MA, Akdeniz N (2019). "Diagnosis and treatment of urticaria in primary care". North Clin Istanb. 6 (1): 93–99. doi:10.14744/nci.2018.75010. PMC 6526977 Check |pmc= value (help). PMID 31180381.
  6. ↑ Stellato C, de Paulis A, Ciccarelli A, Cirillo R, Patella V, Casolaro V; et al. (1992). "Anti-inflammatory effect of cyclosporin A on human skin mast cells". J Invest Dermatol. 98 (5): 800–4. doi:10.1111/1523-1747.ep12499960. PMID 1373749.
  7. ↑ Vena GA, Cassano N, Colombo D, Peruzzi E, Pigatto P, Neo-I-30 Study Group (2006). "Cyclosporine in chronic idiopathic urticaria: a double-blind, randomized, placebo-controlled trial". J Am Acad Dermatol. 55 (4): 705–9. doi:10.1016/j.jaad.2006.04.078. PMID 17010756.
  8. ↑ Barniol C, Dehours E, Mallet J, Houze-Cerfon CH, Lauque D, Charpentier S (2017). "Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial". Ann Emerg Med. doi:10.1016/j.annemergmed.2017.03.006. PMID 28476259.
  9. ↑ Shelley WB, Shelley ED (1985). "Adrenergic urticaria: a new form of stress-induced hives". Lancet. 2 (8463): 1031–3. doi:10.1016/s0140-6736(85)90905-5. PMID 2865515.
  10. ↑ Olafsson JH, Larkö O, Roupe G, Granerus G, Bengtsson U (1986). "Treatment of chronic urticaria with PUVA or UVA plus placebo: a double-blind study". Arch Dermatol Res. 278 (3): 228–31. doi:10.1007/BF00412929. PMID 2425755.
  11. ↑ Horio T (2000). "Indications and action mechanisms of phototherapy". J Dermatol Sci. 23 Suppl 1: S17–21. doi:10.1016/s0923-1811(99)00069-9. PMID 10764986.
  12. ↑ Godt O, Proksch E, Streit V, Christophers E (1997). "Short- and long-term effectiveness of oral and bath PUVA therapy in urticaria pigmentosa and systemic mastocytosis". Dermatology. 195 (1): 35–9. doi:10.1159/000245681. PMID 9267734.
  13. ↑ Baron, ED (2007-03-29). "Urticaria, Solar". WebMD. Retrieved 2007-12-26. Unknown parameter |coauthors= ignored (help)
  14. ↑ McDonald, Kate (2007-04-13). "Tackling skin cancer in organ transplant patients". Australian Life Scientist. Retrieved 2007-12-24.
  15. ↑ Kaplan AP (2017). "Chronic Spontaneous Urticaria: Pathogenesis and Treatment Considerations". Allergy Asthma Immunol Res. 9 (6): 477–482. doi:10.4168/aair.2017.9.6.477. PMC 5603475. PMID 28913986.

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