AMERICAN ACADEMY OF DERMATOLOGY

Chronic
Urticaria

CLINICAL CARE APP

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

DIAGNOSING CHRONIC URTICARIA

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

ACUTE VERSUS CHRONIC URTICARIA

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

CAUSES OF ACUTE URTICARIA AND/OR ANGIOEDEMA

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

PHYSICAL URTICARIA AND/OR ANGIOEDEMA

Physical urticaria is an abnormal response of inflammatory cells to physical stimuli of various types (from most to least common):

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

DIFFERENTIAL DIAGNOSIS

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

PHYSICAL APPEARANCE OF CHRONIC URTICARIA/ANGIOEDEMA

Lesions

Angioedema

Symptoms

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

COMMON DERMATOSES RESEMBLING URTICARIA/ANGIOEDEMA

In patients with chronic urticaria/angioedema, lesions fade within 24-48 hours.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

LESS COMMON OR UNCOMMON DERMATOSES RESEMBLING URTICARIA/ANGIOEDEMA

In patients with chronic urticaria/angioedema, lesions fade within 24-48 hours.
In most of the dermatoses listed below, lesions last for days to weeks.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

SPECIFIC AUTOINFLAMMATORY SYNDROMES RESEMBLING URTICARIA/ANGIOEDEMA

In patients with chronic urticaria/angioedema, lesions fade within 24-48 hours.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

ENDOCRINE, HORMONAL, AND PREGNANCY-RELATED DERMATOSES RESEMBLING URTICARIA/ANGIOEDEMA

In patients with chronic urticaria/angioedema, lesions fade within 24-48 hours.
In most of the dermatoses listed below, lesions last for days to weeks.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

DIAGNOSTIC EVALUATION

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

HISTORY AND PHYSICAL EXAMINATION

History, review of systems, and physical exam aid in determining if symptoms are due to chronic urticaria and which diagnostic or lab testing should be done.

HISTORY

PHYSICAL EXAM

Urticaria

Angioedema

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

LABORATORY EVALUATION

After a thorough history and physical examination, no diagnostic testing may be necessary for some patients with CU; however, limited laboratory testing, based on clinical suspicion, may be appropriate to exclude underlying causes.

For patients with chronic urticaria without atypical features, limited laboratory testing (see below) can be performed; however, this rarely yields clinically significant findings:

Autoantibody testing, allergen skin or serologic testing, and skin biopsy are not recommended on a routine basis

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

ADDITIONAL EVALUATIONS

Additional diagnostic tests might be warranted in individual cases based on history and physical findings, possibly including but not limited to the following:

Additional testing (eg, more detailed lab tests; skin biopsy) may also be warranted:

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

CHALLENGE PROCEDURES FOR PHYSICAL URTICARIA/ANGIOEDEMA SYNDROMES

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

TREATMENT

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

GENERAL MANAGEMENT OF CHRONIC URTICARIA

Management involves pharmacologic and non-pharmacologic approaches.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

STEP-CARE APPROACH TO TREATMENT

  • Monotherapy with 2nd-generation antihistamine
  • Remove/avoid triggers and physical factors (eg, NSAIDs, heat) for patients with physical urticaria/angioedema

One or more of the following:

  • Higher dose of 2nd-generation antihistamine from step 1
  • Add another 2nd-generation antihistamine
  • Add H2 antagonist
  • Add leukotriene receptor antagonist
  • Add 1st-generation antihistamine at bedtime

Dose advancement of potent antihistamine (e.g., hydroxyzine) or doxepin as tolerated

  • Add omalizumab or cyclosporine
  • Add other anti-inflammatories, immunosuppressants, or biologics
  • If alternative agents are deemed necessary for urticaria control, consider referring the patient to a specialist in the treatment of hives

References

  1. Bernstein J, Lang D, Khan D et al. The diagnosis and management of acute and chronic urticaria: 2014 update. Journal of Allergy and Clinical Immunology. 2014;133(5):1270-1277

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

SPECIFIC THERAPEUTIC AGENTS

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

PHARMACOLOGY OF H1 ANTIHISTAMINES

Agents may require dose adjustment for hepatic impairment.
Data are means. NA = not available.
Pregnancy categories are explained below the charts.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

SELECTION OF ALTERNATIVE AGENTS FOR REFACTORY CHRONIC URTICARIA

Note: If alternative agents are deemed necessary for urticaria control, consider referring the patient to a specialist with an expertise in treating hives.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

LABORATORY MONITORING FOR ALTERNATIVE AGENTS USED IN REFACTORY CHRONIC URTICARIA

BUN = blood urea nitrogen; Cr = creatinine; CXR = chest x-ray; K = potassium; LFT = liver function test.

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

ICD-10 Coding

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

SUBMIT FEEDBACK

Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

ABOUT

DISCLAIMER:
The American Academy of Dermatology (the Academy) is providing the information in this web-based app as a member benefit and for educational purposes only. It is not meant to substitute for independent medical judgment of the treating dermatologist relative to the diagnostic, management and treatment options of a specific patient's medical condition. The information in the web-based app is provided as is and the Academy does not warrant the accuracy, reliability, completeness, currentness, or timeliness of the information. The Academy is not responsible for any actions taken in reliance on this web-based app, including but not limited to any treatment decisions made by any health care provider using this web-based app.

Supported by an educational grant from Novartis

American Academy of Dermatology

Correspondence: P.O. Box 4014
  Schaumburg, IL 60168
Toll-free: 866.535 SKIN (7546)
International: 847.240.1280
Fax: 847.240.1859

AUTHORS
Michael Tharp, MD, FAAD
Diane Baker, MD, FAAD
Amit Garg, MD, FAAD
David Khan, MD, FAAAAI
David Lang, MD, FAAAAI
Nicholas Soter, MD, FAAD

CONTRIBUTING AUTHOR
Bernard Cohen, MD, FAAD

STAFF
Christine Presta, Senior Manager, Enduring Materials
Reva Bhushan, MA, PhD, Senior Manager, Evidence-Based Education and Clinical Best Practices
Amanda Bell, Senior Specialist, Enduring Materials
Laura J. Ninger, ELS, Medical Writer
Patrick Tibble, Mobile Application Developer

© Copyright 2015 American Academy of Dermatology. All rights reserved.

DISCLOSURES

Michael D. Tharp, MD, FAAD, Chair

Commercial Interest Financial Relationship Compensation
Anacor Pharmaceuticals, Inc. Principal Investigator Grants/Research Funding
Chugai Pharma Principal Investigator Grants/Research Funding
GlaxoSmithKline Principal Investigator Grants/Research Funding
Kyowa Hakko USA Principal Investigator Grants/Research Funding
Leo Pharma Inc Principal Investigator Grants/Research Funding
Medical Information Network Founder Salary
Novartis Pharmaceuticals Corp. Consultant Honoraria
Regeneron Principal Investigator Grants/Research Funding
Unilever Home & Personal Care USA Advisory Board Grants/Research Funding
XOMA (US) LLC Principal Investigator Grants/Research Funding

Diane R. Baker, MD, FAAD

Commercial Interest Financial Relationship Compensation
Amgen Principal Investigator Grants/Research Funding
AstraZeneca Other Grants/Research Funding
Biocryst Other No Compensation
Circassia Limited Other Grants/Research Funding
CSL Behring Other Grants/Research Funding
Dyax Corp. Other Grants/Research Funding
Genentech, Inc. Other Grants/Research Funding
GlaxoSmithKline Other Grants/Research Funding
Maruho, Co., Ltd. Principal Investigator Grants/Research Funding
Merck & Co., Inc. Principal Investigator Grants/Research Funding
Mylan Technologies Inc. Other Grants/Research Funding
Novartis Pharmaceuticals Corp. Principal Investigator Grants/Research Funding
Pearl Therapeutics Other Grants/Research Funding
Pfizer Inc. Principal Investigator Grants/Research Funding
Pharming Other Grants/Research Funding
Pharming Other Grants/Research Funding
Regeneron Principal Investigator No Compensation Received
Sanofi-aventis Other Grants/Research Funding
Shire Other Grants/Research Funding
Teva Pharmaceuticals USA Other Grants/Research Funding
Tigercat Pharma, Inc Principal Investigator Grants/Research Funding
ViroPharma Incorporated Other Grants/Research Funding

Bernard Cohen, MD, FAAD

Commercial Interest Financial Relationship Compensation
sanofi-aventis Advisory Board Honoraria

Amit Garg, MD, FAAD

Commercial Interest Financial Relationship Compensation
AbVie Advisory Board Honoraria
Eli Lilly and Company Advisory Board Honoraria
Pfizer Inc. Advisory Board Honoraria

David A. Khan, MD, FAAAAI

Baxter Speaker's Bureau Honoraria
Genentech Speaker's Bureau Honoraria
Merck Speaker's Bureau Honoraria

David M. Lang, MD, FAAAAI

Commercial Interest Financial Relationship Compensation
Hycor Consultant Fees
Quest Consultant Fees
Genentech Speaker Honoraria
Novartis Speaker Honoraria
Merck Advisory Board Fees

Nicholas A. Soter, MD, FAAD

Commercial Interest Financial Relationship Compensation
None None None

Mandy Bell
AAD Staff

Commercial Interest Financial Relationship Compensation
None None None

Reva Bhushan, MA, PhD
AAD Staff

Commercial Interest Financial Relationship Compensation
None None None

Christine Presta
AAD Staff

Commercial Interest Financial Relationship Compensation
None None None

Acknowledgement
The American Academy of Dermatology gratefully acknowledges the American Academy of Allergy, Asthma & Immunology's contributions in the development of this mobile application.


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Chronic Urticaria

AMERICAN ACADEMY OF DERMATOLOGY

REFERENCES

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