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Welcome back! In the last article, we have uncovered the signs and symptoms of urticaria, which include itchy, raised, and well-defined bumps on the skin, also known as wheals. The condition is typically caused by allergies or infections but can also be triggered by stress, vibration, or sudden environmental changes. Diagnosing urticaria involves evaluating the patient's medical history, conducting physical examinations, and, in some cases, using skin prick tests or blood tests to identify potential triggers. The discomfort and itchiness associated with urticaria can affect individuals of all ages, including children. Now, with the knowledge we've gained, join us once again as we dive into the ABCs of urticaria management this time!
It's important to note that the proper identification of urticaria subtypes is essential for effective management and treatment. Urticaria is classified based on its duration and potential triggers:
Acute Urticaria: This type lasts for up to 6 weeks and is characterised by the appearance of wheals, and sometimes swelling, called angioedema.
Chronic Urticaria (CU): Lasting beyond six weeks, chronic urticaria can manifest with daily or intermittent symptoms. Occasionally, it may resolve temporarily, only to reappear later. There are two types of CU’s:
Chronic Inducible Urticaria (CIndU) consistently occurs when the triggering factor is present and ceases when the trigger is removed.
Chronic Spontaneous Urticaria (CSU) occurs unpredictably, often without identifiable causes. Some CSU patients may experience occasional triggers such as specific foods, medications, or infections, which can exacerbate the condition. However, these triggers are inconsistent and do not always lead to hives.
There are a few types of inducible urticaria that are worth a mention. First of all, there is dermographism where the skin reacts to stroking or scratching. It can also be triggered by wearing tight clothing or towel-drying the skin after a hot shower. On the other hand, contact urticaria is caused by substances absorbed through the skin or mucous membrane and can be triggered by allergens such as white flour, cosmetics, textiles, latex, saliva, meat, fish, and vegetables.
Identifying and avoiding triggers play a pivotal role in managing urticaria. Even when the trigger remains unidentified, urticaria usually resolves over a period of days to weeks. with acute urticaria usually self-limited, and individual lesions commonly resolve within 24 hours but episodes may recur for up to 6 weeks. Usually, each wheal from urticaria disappears within a day without any special treatment. However, angioedema, which is related to hives and occurs deeper within the skin, may take up to 72 hours to completely resolve.  .
The first step into dealing with hives is to figure out what the trigger is and then avoid that trigger. . For instance, individuals with cold urticaria should dress warmly in cold or windy conditions and refrain from swimming in cold water. Likewise, those with symptomatic dermographism should reduce friction and avoid tight-fitting clothing.
Nevertheless, complete avoidance of triggers is nearly impossible, and even minor exposure can lead to symptom recurrence as the triggers that set off their symptoms do not need to be very intense.
Pharmacological treatment for urticaria follows a straightforward approach, regardless of the underlying cause.
The primary treatment for urticaria involves antihistamine medications.There are two types of antihistamines: older ones and newer ones, which are also called first-generation antihistamines and second-generation antihistamines respectively.
Table 1: Comparisons between First-generation and Second-generation antihistamines
All in all, second-generation antihistamines are preferred and currently serve as first-line treatment for all forms of urticaria in adults and children because they have fewer side effects and do not cause drowsiness.
While systemic treatment during pregnancy and breastfeeding is generally discouraged, second-generation antihistamines, such as loratadine and cetirizine, are considered safe options if treatment becomes necessary..
In the case of paediatric patients, first-generation antihistamines have a less favourable safety profile compared to their second-generation counterparts. Therefore, they are not recommended as the first choice of treatment for children with urticaria. Instead, second-generation antihistamines have been proven to be effective and safe for paediatric patients.
When deciding which newer antihistamine to use for children with urticaria, factors such as age and availability should be considered, as not all of them are available in forms suitable for children, such as syrups or fast-dissolving tablets .
Here's a real-world success case of someone benefiting from the medication . A 10-year-old boy had been experiencing itchy and recurrent urticaria almost daily for 3-4 years. Despite trying different antihistamine medications, the hives kept coming back 2-3 times per week, affecting his school attendance and sleep. Tests did not find any specific triggers, and he was not responding well to previous treatments. Then, his doctor switched him to a non-sedative antihistamine, which he only had to take once a day. This new medication worked much better for him, and the hives stopped appearing from day 3 onwards. His sleep improved, and he could attend school without any issues from the hives. He also felt more confident with his friends and no longer needed to avoid certain foods or limit their outdoor activities due to the hives. The new medication was more convenient for him and his parents, as it was easy to take and didn't require refrigeration. Needless to say, the non-sedative antihistamine brought him much-needed relief from chronic hives.
In conclusion, effective management of urticaria demands a good understanding of its subtypes and triggers. The classification of urticaria into acute, chronic, and inducible forms provides a crucial foundation for tailored treatment approaches. While non-pharmacological strategies emphasise trigger identification and avoidance, recognizing that complete avoidance is often challenging due to the unpredictable nature of triggers is essential. Pharmacological intervention primarily involves antihistamines, with second-generation antihistamines being the preferred choice for their efficacy and minimal side effects in both adults and children.
Want to know more about rhinitis from DOC2US? Stay tuned for our next articles where we debunk myths related to rhinitis and dive deeper into its management!
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The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria https://research.rug.nl/files/211907798/The_international_EAACIGA_LENEuroGuiDermAPAAACI_guideline_for_the_definition_classification_diagnosis_and_management_of_urticaria.pdf
DermNET: Urticaria – an overview https://dermnetnz.org/topics/urticaria-an-overview
UpToDate: Patient education: Hives (urticaria) (Beyond the Basics) https://www.uptodate.com/contents/hives-urticaria-beyond-the-basics/print
Medscape: Urticaria Treatment & Management https://emedicine.medscape.com/article/762917-treatment
Experience with bilastine in the management of urticaria: Original Real-world cases of Bilastine In Treatment (ORBIT) in Asia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932249/
In collaboration with Menarini
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