From the Guidelines
The treatment of pressure urticaria primarily involves avoiding pressure triggers and using medications to control symptoms, with first-line therapy including non-sedating H1 antihistamines such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) as the mainstay of therapy, as supported by the guidelines for evaluation and management of urticaria in adults and children 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life by alleviating symptoms and preventing complications. Key considerations in the management of pressure urticaria include:
- Avoiding pressure triggers through practical measures such as wearing loose-fitting clothing, using padded seating, and distributing weight evenly when carrying items
- Using medications to control symptoms, with antihistamines being the primary treatment option
- Considering adjunctive therapies such as leukotriene receptor antagonists or immunosuppressants for severe or refractory cases, as suggested by the guidelines for evaluation and management of urticaria in adults and children 1
- Maintaining a symptom diary to identify specific triggers and monitor response to treatment The use of oral corticosteroids like prednisone (20-40mg daily for 3-5 days) may be considered for short courses during severe flares, but their long-term use is not recommended due to side effects, as noted in the guidelines for evaluation and management of urticaria in adults and children 1. Immunosuppressants such as cyclosporine (3-5mg/kg/day) or omalizumab (300mg subcutaneously every 4 weeks) may be considered for treatment-resistant cases under specialist supervision, as suggested by the guidelines for evaluation and management of urticaria in adults and children 1. Referral to a specialist, such as an allergist-immunologist, may be necessary for patients with chronic urticaria or angioedema, or those with suspected or proved cutaneous or systemic mastocytosis, as outlined in the consultation and referral guidelines citing the evidence 1.
From the Research
Treatment Options for Pressure Urticaria
- Antihistamines are the mainstay of treatment for urticaria, including pressure urticaria, as stated in 2 and 3
- Second-generation H1 antihistamines (sgAHs) are effective in some cases of pressure urticaria, according to 3
- The combination of an sgAH and montelukast or an sgAH and theophylline may be more effective than an sgAH alone, as reported in 3
- Other treatment options for pressure urticaria include omalizumab, sulphones, oral prednisolone, intravenous immunoglobulin, and a gluten-free diet, as mentioned in 3
Considerations for Treatment
- The quality of studies on pressure urticaria is generally low, making it difficult to determine the most effective treatment, as noted in 3
- Updosing of second-generation antihistamines could be considered in patients with uncontrolled symptoms, although there is no evidence of its efficacy over standard dosage, as stated in 3
- Addition of montelukast may be considered for patients with pressure urticaria, according to 3
- Omalizumab or sulphones may be used in treatment-resistant patients, as reported in 3
Comparison to Other Forms of Urticaria
- Treatment of pressure urticaria is similar to that of other forms of urticaria, with antihistamines being the first-line treatment, as stated in 2 and 4
- However, the effectiveness of antihistamines may vary depending on the specific type of urticaria, as noted in 2 and 3
- Other forms of urticaria, such as solar urticaria, may require tailored treatment regimens, as reported in 5