From the Guidelines
Management of exercise-induced urticaria in children should prioritize preventive measures, including the use of non-sedating antihistamines and lifestyle adjustments, to minimize the risk of severe reactions and anaphylaxis. The most recent and highest quality study 1 suggests that exercise-induced anaphylaxis, which can be related to exercise-induced urticaria, requires careful management to prevent severe outcomes. Key preventive measures include:
- Taking non-sedating antihistamines like cetirizine (0.25 mg/kg/day), loratadine (5-10 mg daily based on age), or fexofenadine (30-60 mg twice daily for children 6-11 years, 180 mg daily for older children) 1-2 hours before exercise
- Avoiding exercise within 4-6 hours after eating potential trigger foods
- Gradual warm-up before exercise
- Avoiding exercise in extreme temperatures
- Postponing exercise during high pollen days for children with allergies
In addition to these measures, children with exercise-induced urticaria should always carry an epinephrine auto-injector (e.g., EpiPen Jr 0.15 mg for children under 30 kg, or EpiPen 0.3 mg for those over 30 kg) for severe reactions, as exercise-induced urticaria can occasionally progress to anaphylaxis 1. Parents and school staff should be educated about recognizing symptoms and implementing an action plan. With proper management, most children can continue to participate in physical activities safely. It is also important to note that some patients may have specific food triggers that can be identified and avoided to prevent exercise-induced anaphylaxis, as suggested by 1.
From the Research
Management of Exercise-Induced Urticaria in Children
- The management strategy for patients who have exercise-induced syndromes with skin manifestations only differs from the management for those with systemic symptoms 2.
- Antihistamines, as a single agent or in combination with other agents, may be helpful prophylactically in both groups 2.
- Avoidance of precipitating factors, modification of exercise, and use of a self-injectable epinephrine kit are recommended for patients with anaphylaxis 2, 3.
- The treatment of acute episodes of exercise-induced urticaria includes administration of epinephrine and antihistamines, airway maintenance, and cardiovascular support 3.
- Prophylactic treatment includes exercise avoidance, abstention from coprecipitating foods and medications, pretreatment with antihistamines and cromolyn, and the induction of tolerance through regular exercise 3.
Treatment Approaches
- The currently recommended first line treatment for urticaria in children is application of oral nonsedating H1 antihistamines 4.
- If needed, the dosage of antihistamines should be up to two-fold, although evidence is lacking for this, whereas alternative treatment should be reserved as add-on therapy for unresponsive patients 4.
- Management is centered upon avoidance of eliciting factors, where emergency plans are individualized, except a mandatory prescription of an adrenaline auto-injector 5.
Diagnostic Considerations
- The morphologic size of the urticarial wheals can help distinguish between exercise-induced anaphylaxis and cholinergic urticaria, with small punctate wheals present in cholinergic urticaria and large ones in exercise-induced anaphylaxis 6.
- Wheat is the most common food associated with food-dependent exercise-induced anaphylaxis and gluten is its most important antigen, with omega-5-gliadin being the major epitope of gluten 6.