What is the initial approach to an elderly patient presenting with an outbreak of hives and no acute pancreatitis?

Evaluation of Hives in an Elderly Patient

In an elderly patient presenting with hives (urticaria) without acute pancreatitis, begin with a focused assessment for drug reactions, recent medication changes, and underlying systemic diseases, as this population has higher risk for medication-induced urticaria and occult malignancy.

Initial Clinical Assessment

Medication History

• Obtain a detailed drug history including all prescription medications, over-the-counter drugs, and supplements started within the past 6 weeks, as drug-induced urticaria is common in elderly patients 1
• Pay particular attention to recent antibiotic use, NSAIDs, ACE inhibitors, and any new medications, as these are frequent culprits in elderly populations 1

Focused History Elements

• Document the timing and pattern of hive outbreaks: acute (< 6 weeks) versus chronic (> 6 weeks), as this distinction guides further workup 1
• Assess for allergic triggers including seasonal patterns (particularly September to February), environmental exposures, and food allergens 2
• Screen for systemic symptoms including fever, weight loss, joint pain, or fatigue that might suggest underlying autoimmune or malignant processes 1

Laboratory Evaluation

Initial Testing

• Complete blood count with differential to assess for eosinophilia, which may suggest allergic etiology 2
• Serum IgE levels if allergic mechanism is suspected based on history 2
• Basic metabolic panel and liver function tests to exclude systemic disease 1

Age-Specific Considerations

• In elderly patients, consider malignancy screening if urticaria is persistent or associated with constitutional symptoms, as occult tumors can present with paraneoplastic urticaria 1
• Thyroid function tests and autoimmune markers may be warranted if chronic urticaria persists beyond 6 weeks, as autoimmune conditions can manifest with cutaneous findings 2

Management Approach

Immediate Interventions

• Discontinue any potentially offending medications identified in the drug history review 1
• Initiate second-generation H1-antihistamines (e.g., cetirizine, loratadine) as first-line therapy for symptomatic relief 2
• Assess for angioedema or respiratory compromise requiring urgent intervention, though this is less common with simple urticaria 1

Monitoring Strategy

• Serial clinical reassessment to detect progression or development of systemic symptoms 3, 4
• If urticaria persists beyond 6 weeks, escalate workup to include comprehensive autoimmune panel and consider dermatology referral 2

Critical Pitfalls to Avoid

• Do not assume urticaria is benign in elderly patients without excluding underlying systemic disease, particularly malignancy 1
• Avoid empiric antibiotic therapy unless there is clear evidence of infection, as antibiotics themselves can cause or worsen urticaria 1
• Do not overlook seasonal patterns that may suggest allergic rhinitis or other atopic conditions requiring specific management 2

When to Escalate Care

• Refer to allergy/immunology if urticaria becomes chronic (> 6 weeks) or fails to respond to standard antihistamine therapy 2
• Consider imaging (CT scan) in elderly patients with persistent unexplained urticaria and constitutional symptoms to exclude occult malignancy 1
• Urgent evaluation required if angioedema, respiratory symptoms, or signs of anaphylaxis develop 1