What is the treatment for genital urticaria?

Treatment of Genital Urticaria

Second-generation antihistamines are the first-line treatment for genital urticaria, with doses that can be increased up to four times the standard dose for patients with inadequate response. 1

First-Line Treatment

Antihistamine Therapy

• Start with second-generation H1-antihistamines to minimize sedation:

  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily

• If response is inadequate after 1-2 weeks, increase the dose up to 4 times the standard dose (e.g., cetirizine 40mg daily) 1

• Avoid first-generation (sedating) antihistamines, especially in elderly patients due to increased fall risk and cognitive impairment

Second-Line Treatment Options

For cases resistant to maximum-dose antihistamines:

1. Add leukotriene receptor antagonists (e.g., montelukast) as adjunctive therapy 1

2. Omalizumab (300mg subcutaneously every 4 weeks) for chronic spontaneous urticaria not responding to antihistamines 1

   • Should be administered in healthcare settings with observation for at least 30 minutes after injection
   • First three injections require extended observation (2 hours) due to higher risk of anaphylaxis

3. Cyclosporine (4mg/kg daily) for severe cases unresponsive to antihistamines

   • Effective in approximately two-thirds of patients with severe autoimmune urticaria
   • Recommended treatment duration of 16 weeks 1

Topical Treatments for Genital Area

Due to the sensitive nature of genital skin:

• Low-potency topical corticosteroids for short-term use (1-2 weeks) to control acute flares

  • Apply sparingly to affected areas
  • Avoid prolonged use to prevent skin atrophy

• Topical calcineurin inhibitors (tacrolimus 0.03-0.1% ointment or pimecrolimus 1% cream) may be used as steroid-sparing agents for longer-term management 2

Special Considerations for Genital Area

1. Potential allergen identification and avoidance is crucial as the genital area has high exposure to various allergens 3:

   • Personal hygiene products
   • Contraceptives (especially latex condoms)
   • Topical medications (local anesthetics, preservatives)
   • Spermicides and lubricants

2. Avoid potential irritants:

   • Fragranced products
   • Harsh soaps
   • Tight-fitting synthetic underwear

3. Consider infectious triggers - some cases of genital urticaria may be associated with recurrent genital herpes simplex infections 4

   • In such cases, adding acyclovir to antihistamine therapy may be beneficial

Monitoring and Assessment

• Regularly assess treatment response within 1-2 weeks of initiating or changing therapy
• Use validated tools like UAS7 (Urticaria Activity Score over 7 days) if available
• Consider step-down protocols in patients with complete disease control to assess for spontaneous remission 1

Emergency Management

• Epinephrine is the first-line treatment for severe symptoms or signs of anaphylaxis
• Patients with severe episodes should have an epinephrine auto-injector available and be educated on its use 1

Patient Education

• Genital urticaria is often underreported and undertreated due to patient embarrassment 5
• Encourage open discussion about genital symptoms
• Reassure patients that genital involvement in urticaria is common (affecting up to 58% of urticaria patients) 5
• Emphasize the importance of adherence to medication regimens

The treatment approach should be adjusted based on symptom severity, patient response, and impact on quality of life, with the goal of complete symptom control.