From the Guidelines
The most effective treatment for pressure urticaria is a combination of non-sedating antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), and avoidance strategies, with the option to add leukotriene receptor antagonists like montelukast (10mg daily) for more severe cases. The choice of antihistamine should be individualized, as responses and tolerance vary between patients 1. It is also common practice to increase the dose of antihistamines above the licensed recommendation for patients who do not respond, as the potential benefits may outweigh the risks 1.
For patients with severe or refractory pressure urticaria, immunomodulating therapies such as ciclosporin may be considered, as it has been shown to be effective in about two thirds of patients with severe autoimmune urticaria unresponsive to antihistamines 1. However, the optimal patient selection, dose, and duration of treatment still need to be defined.
Practical management of pressure urticaria should include:
- Identifying and avoiding pressure triggers
- Using padding for areas subject to pressure
- Wearing loose-fitting clothing
- Considering the use of corticosteroids such as prednisone (20-40mg daily for 3-5 days) for acute flares, although long-term use is not recommended due to side effects.
It is essential to note that pressure urticaria occurs when sustained pressure on the skin causes release of histamine and other inflammatory mediators from mast cells, leading to swelling and pain that typically develops 4-6 hours after pressure application and may last up to 48 hours, making it distinct from immediate pressure urticaria and requiring targeted treatment approaches.
From the Research
Treatment Options for Pressure Urticaria
- The mainstay of treatment for urticaria, including pressure urticaria, is antihistamines 2
- Second-generation H1 antihistamines, such as cetirizine, fexofenadine, and loratadine, are preferred due to their reduced sedative and anticholinergic effects 2, 3
- First-generation H1 antihistamines, such as hydroxyzine, may be used for severe symptoms or in combination with other treatments 4, 3
- Leukotriene receptor antagonists, such as montelukast, may be used as adjunctive treatment for refractory cases 4, 5
- Corticosteroids may be used for short-term relief in severe cases, but long-term use should be avoided due to potential side effects 4, 3
Specific Treatment Regimens
- A study comparing cetirizine and fexofenadine found that cetirizine had a therapeutic advantage in the treatment of chronic idiopathic urticaria 6
- A study on solar urticaria found that a combination of antihistamines and leukotriene receptor antagonists was effective in tailoring treatment regimens to disease severity 5
- Another study suggested that omalizumab or cyclosporine may be used as additional treatments for refractory chronic urticaria 3
Considerations for Treatment
- Treatment should be individualized based on disease severity and patient response 5
- A step-by-step approach to management, starting with antihistamines and adding other treatments as needed, is recommended 4
- Patients with refractory chronic urticaria may require referral to subspecialists for additional treatments 3