What is the recommended management for urticaria in elderly patients?

Management of Urticaria in Elderly Patients

For elderly patients with urticaria, first-line treatment should include emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema, followed by non-sedating antihistamines if symptoms persist, with careful avoidance of sedating antihistamines due to their adverse effects in this population. 1

Initial Assessment and First-Line Treatment

1. Initial management:

   • Apply emollients with high lipid content (preferred in elderly) 1
   • Use topical steroids for at least 2 weeks to exclude asteatotic eczema 1
   • Consider topical clobetasone butyrate or menthol for symptomatic relief 1

2. Pharmacological approach if initial treatment fails:

   • Non-sedating antihistamines (first choice): 1, 2

     • Fexofenadine 180 mg once daily
     • Loratadine 10 mg once daily
     • Cetirizine 10 mg once daily (mildly sedating)

   • Step-up approach: If standard dose is ineffective, increase dose up to 4 times the standard dose 2, 3

     • Example: Fexofenadine 180 mg → up to 720 mg daily
     • Example: Loratadine 10 mg → up to 40 mg daily

Important Cautions for Elderly Patients

• AVOID sedative antihistamines (Strength of recommendation C) 1, 4

  • First-generation antihistamines like diphenhydramine and hydroxyzine should not be used due to:
    • Increased risk of falls
    • Cognitive impairment
    • Anticholinergic side effects
    • Potential for drug interactions

• AVOID topical treatments: 1

  • Crotamiton cream (Strength of recommendation B)
  • Topical capsaicin
  • Calamine lotion

Second-Line Options

If symptoms persist despite increased doses of non-sedating antihistamines:

1. Consider H1 and H2 antagonists in combination: 1, 2, 5

   • Fexofenadine plus cimetidine
   • Particularly effective for symptomatic dermographism

2. Consider gabapentin: 1

   • May benefit elderly patients with pruritus
   • Requires careful dose titration in elderly

3. Topical doxepin (limited use): 1, 2

   • Treatment should be limited to 8 days
   • Apply to no more than 10% of body surface area
   • Maximum 12g daily
   • Monitor for allergic contact dermatitis

Advanced Therapy Options

For refractory cases that don't respond to the above treatments:

1. Omalizumab: 2

   • For chronic spontaneous urticaria unresponsive to antihistamines
   • Dosage: 300mg every 4 weeks
   • Monitor for anaphylaxis risk

2. Other options to consider: 1, 2

   • Leukotriene receptor antagonists (e.g., montelukast)
   • Paroxetine, mirtazapine, or pregabalin
   • Cyclosporine (requires blood pressure and renal function monitoring)

Monitoring and Follow-up

• Reassess patients who have not responded to initial treatment 1
• Use validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control 2
• Consider step-down only after at least 3 consecutive months of complete control 2
• Refer to secondary care if: 1
  • Diagnostic doubt exists
  • Primary care management does not relieve symptoms

Common Pitfalls in Managing Elderly Patients with Urticaria

• Using sedating antihistamines: Can cause significant cognitive impairment, falls, and anticholinergic effects in elderly 4
• Inadequate dose adjustment: Physiological changes in elderly may require dose adjustments based on renal/hepatic function 4
• Missing underlying causes: Always consider potential systemic causes of urticaria in elderly patients
• Drug interactions: Be vigilant about potential interactions with other medications commonly used by elderly patients 4

If urticaria is accompanied by signs of anaphylaxis, epinephrine is the first-line treatment, followed by combined H1+H2 blockade, and emergency care should be sought immediately 2.