What is the management for transient lesions and urticaria?

Management of Transient Lesions and Urticaria

Second-generation H1 antihistamines at standard doses, with progressive increase up to 4 times the dose if necessary, are the first-line treatment for urticaria, before considering other therapies such as omalizumab or cyclosporine. 1

Classification and Diagnosis

Urticaria presents with:

• Erythematous, edematous, itchy, and transient plaques
• Lesions typically resolve within 2-3 hours without a trace 2
• May be accompanied by angioedema (swelling of deeper tissues)

Types of urticaria:

• Acute spontaneous urticaria (lasting <6 weeks)
• Chronic spontaneous urticaria (lasting >6 weeks)
• Physical urticarias (triggered by specific stimuli)
• Episodic chronic urticaria

Treatment Algorithm

First-line Treatment

1. Non-sedating second-generation H1 antihistamines at standard doses 1:
   • Cetirizine 10 mg/day
   • Loratadine 10 mg/day
   • Fexofenadine 180 mg/day
   • Desloratadine 5 mg/day

Second-line Treatment (if inadequate response after 2 weeks)

1. Increase dose of second-generation H1 antihistamines up to 4 times the standard dose 1:
   • Cetirizine up to 40 mg/day
   • Loratadine up to 40 mg/day
   • Fexofenadine up to 720 mg/day

Third-line Treatment (for refractory cases)

1. Add one or more of the following 1, 3:
   • Leukotriene receptor antagonists
   • H2 antihistamines (ranitidine, cimetidine)
   • Omalizumab (300mg subcutaneously every 4 weeks)
   • Cyclosporine (up to 5mg/kg body weight with monitoring)

For Acute Exacerbations

• Short-course systemic corticosteroids (3-10 days) 1:
  • Prednisone 0.5-1 mg/kg/day until symptoms resolve to grade 1
  • Avoid prolonged use due to adverse effects

Special Considerations

Angioedema and Anaphylaxis

If urticaria is accompanied by angioedema or signs of anaphylaxis:

• Epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment 1
• Followed by combined H1+H2 blockade:
  • Diphenhydramine (1-2 mg/kg or 25-50 mg IV) plus
  • Ranitidine (50 mg IV)
• Seek immediate emergency medical attention

Important Cautions

• Avoid first-generation antihistamines (such as diphenhydramine) due to sedating and anticholinergic effects, especially in elderly patients 1
• Prolonged use of corticosteroids should be avoided due to adverse effects 1
• Allow at least 2 weeks to assess efficacy before changing treatment 1

For Physical Urticarias

• Identify and avoid specific triggers 4
• For symptomatic dermatographism, consider combination of an antihistamine and an H2 antagonist 5

For Pediatric Patients

• Use age-appropriate, weight-based dosing of second-generation H1-antihistamines 1
• Consider food allergies as a common cause in infants 1

Monitoring and Follow-up

• Evaluate response to treatment after 2 weeks before modifying therapy 1
• Use validated tools such as the Urticaria Control Test (UCT) and the Urticaria Activity Score (UAS7) to monitor disease control 1
• Refer to specialists if:
  • Diagnostic doubt exists
  • Primary care management fails to relieve symptoms
  • Chronic urticaria is refractory to standard treatments

Treatment Outcomes

• More than half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 3
• Approximately 65-87% of patients with chronic spontaneous urticaria respond to omalizumab therapy 1

The management approach should focus on symptom control, identifying and avoiding triggers when possible, and escalating therapy in a stepwise manner for refractory cases.