From the Guidelines
The management of delayed pressure urticaria primarily involves a combination of preventive measures and medication therapy, with first-line treatment including non-sedating H1 antihistamines such as cetirizine (10 mg daily), fexofenadine (180 mg daily), or loratadine (10 mg daily), which may need to be increased up to four times the standard dose for adequate symptom control, as recommended by guidelines for evaluation and management of urticaria in adults and children 1.
Medication Therapy
The following medications can be used to manage delayed pressure urticaria:
- Non-sedating H1 antihistamines: cetirizine (10 mg daily), fexofenadine (180 mg daily), or loratadine (10 mg daily) 1
- Leukotriene receptor antagonists: montelukast (10 mg daily) for patients with inadequate response to antihistamines
- Immunossuppressive medications: cyclosporine (3-5 mg/kg/day in divided doses) or omalizumab (300 mg subcutaneous injection every 4 weeks) for severe or refractory cases
- Short courses of oral corticosteroids: prednisone (20-40 mg daily for 3-5 days) to manage acute flares, but should be avoided for long-term use due to side effects 1
Preventive Measures
Practical preventive measures include:
- Avoiding prolonged pressure on the skin
- Using padded supports when carrying heavy objects
- Wearing loose-fitting clothing
- Using pressure-distributing mattresses
Treatment Response
Treatment response should be monitored regularly, with medication adjustments as needed. This condition is particularly challenging to manage because the delayed nature of symptoms (appearing 4-6 hours after pressure application) makes it difficult to identify triggers, and the deep dermal and subcutaneous inflammation often responds less readily to standard urticaria treatments. Other treatment options, such as sulfasalazine or dapsone, may be successful in otherwise corticosteroid-dependent cases, but the evidence for these treatments is anecdotal 1.
From the Research
Management of Delayed Pressure Urticaria
The management of delayed pressure urticaria (DPU) is complex and challenging, as it often coexists with chronic "idiopathic" urticaria and does not respond well to traditional treatments such as H1-antihistamines 2.
- Treatment Options: Various treatment alternatives have been proposed for severe refractory cases, including:
- Oral or topical corticosteroids 2
- Anti-inflammatory drugs 2
- Sulfasalazine, which has been shown to be effective in some cases 3
- Omalizumab, a monoclonal antibody that binds free immunoglobin E, which has been found to be effective in patients with DPU refractory to antihistamines 4, 5
- Cyclosporine, an immunosuppressant, which has been used in combination with other treatments to achieve control of symptoms 6
- Antihistamines: While antihistamines are often not effective in treating DPU, second-generation H1 antihistamines (sgAHs) have been found to be effective in some cases, and updosing of sgAHs could be considered in patients with uncontrolled symptoms 4
- Combination Therapy: Combination treatment with a second-generation antihistamine, a leukotriene receptor antagonist, and an immunosuppressant (such as cyclosporine) has been found to be effective in achieving control of symptoms in some cases 6
- Omalizumab: Omalizumab has been found to be a rapid, effective, and safe treatment for patients with DPU refractory to antihistamines in an up-dosing regimen, and is recommended for patients who do not respond to up-dosing antihistamines and montelukast 5