From the Guidelines
Urticaria is a skin reaction characterized by raised, red, itchy welts that can appear anywhere on the body, and its management should prioritize the use of antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), as first-line treatment, with the option to updose up to 4-fold higher if necessary, as recommended by the latest guidelines 1.
Definition and Classification
Urticaria, commonly known as hives, can be acute (lasting less than six weeks) or chronic (persisting beyond six weeks), and it can be classified into different types, including:
- Ordinary urticaria: acute, episodic, or chronic
- Physical urticarias: triggered by physical stimuli, such as mechanical or thermal factors
- Contact urticaria: occurs when an allergen is absorbed percutaneously or through mucous membranes
- Urticarial vasculitis: presents with urticaria clinically but small vessel vasculitis histologically
- Autoinflammatory syndromes: presenting with urticaria, pyrexia, and malaise, with other features that define the disease phenotype
Management
The management of urticaria should focus on identifying and avoiding triggers, and the use of pharmacologic treatment, such as:
- Antihistamines: as first-line treatment, with the option to updose up to 4-fold higher if necessary
- Omalizumab: as second-line treatment, with a recommended starting dose of 300 mg every 4 weeks, and the option to updose if necessary
- Cyclosporine: as third-line treatment, with a recommended dose of 2-5 mg/kg/day, and careful monitoring of blood pressure and renal function
Key Considerations
- The duration of individual weals can be helpful in distinguishing between different clinical patterns, with weals typically lasting from 2 to 24 hours in ordinary urticaria, and up to 2 hours in contact urticaria 1
- The use of an "as much as needed and as little as possible" approach, by stepping up and stepping down the treatment of urticaria, based on levels of disease control assessed with the UCT, is recommended 1
From the Research
Definition and Classification of Urticaria
- Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life 2
- It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators 2
- Urticaria can be classified into acute and chronic urticaria, with chronic urticaria further divided into spontaneous and inducible types 2
Epidemiology and Disease Burden
- Urticaria has a significant impact on quality of life and is linked to psychiatric comorbidities and high healthcare costs 2, 3
- The condition affects a large portion of the population, with up to 20% of people experiencing urticaria at some point in their lives 2
Diagnosis and Work-up
- The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes or triggers 2, 3
- A comprehensive review of urticaria should include epidemiology, diagnosis, and work-up, taking into account recent literature and best available evidence 3
Treatment Options
- Current treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab, and cyclosporine 2
- Montelukast, a leukotriene receptor antagonist, may be effective for certain cases of urticaria, particularly for patients who are not sufficiently controlled with histamine H(1)-receptor antagonists 4, 5