How Do You Treat Chronic Urticaria?

Patient Presentation
A 21-year-old female came to clinic in the afternoon with a 5-6 week history of hives.
She initially noticed herself itching in the later evening especially on her trunk. She didn’t really notice any reason for the itching nor any skin that was reddened or discolored.
She had difficulty falling asleep because of the itching.
Over the next few days she noticed that the itching recurred but now it also was on her feet and around her waistband in the evening.
Over the next few weeks, she had increasing itching that now would occur in the afternoon and evening and involved her feet, especially the soles and between her toes, around her waistband, shirt wristband, flexural area of elbows, and was especially pronounced where she wore her bra.
She also noticed in the morning that she would have some itching of the back of her head and buttocks, but not other areas. Once the afternoon or evening episodes began, they did not stop until she was sleeping.
The morning episodes would occur after wakening and stop sometime after she was in school.
She stated that reddened areas of her skin with central white papular areas occurred. These areas came and went.
The pruritus did not stop her from her activities but was very annoying and socially embarrassing at times. She tried diphenhydramine with little or no relief.
She denied any new lotions, soaps, shampoos, detergents, makeup, or perfume. She had not had any new intense light exposure.
She denied any medications or recent illness including upper respiratory tract diseases. She said she had no problems eating, drinking or breathing.
The past medical history showed a healthy female with otitis media as a young child. She did not have a history of allergies or skin problems.
The family history was positive for a maternal aunt with hyperthyroid disease.
The review of systems was otherwise negative.
The pertinent physical exam showed a healthy female with normal growth parameters.
Her skin examination showed fine urticarial lesions on her soles, trunk along her bra (especially under the breasts), and abdomen around the waistband.
She had no excoriations of the skin. Stroking the skin with the top of a pen did not elicit a wheal and flare reaction.
She had some freckling on her face, upper arms, upper legs and shoulders. Several freckles were stroked and did not elicit a wheal and flare reaction either.
The diagnosis of a physical urticaria was made most likely a pressure urticaria. The work-up included doing thyroid function and thyroid autoantibody testing because of the family history and possibility of asymptomatic thyroid disease being the inciting cause. The testing was negative.
The patient’s clinical course over the next 2-3 weeks improved after taking over-the-counter loratadine daily.

Chronic urticaria is defined as wheals that occur at least twice weekly for more than 6 weeks. Because this is broad, some people add that the wheals must be present for more than 1 hour (which distinguishes chronic urticaria from dermatographism) and less than 24-36 hours (which distinguishes it from urticaria-vasculitis).
The lesions can be ‘just’ irritating or very painful and even indurated. Outbreaks can occur for weeks-years and affects up to 3 % of the population. Generally there are no systemic problems but some patients have greatly diminished quality of life that is equivalent to people with severe coronary artery disease.
Chronic urticaria can be caused by a specific physical stimulus or often is idiopathic. Up to 1/3 of idiopathic cases appear to be autoimmune related, particularly associated with antithyroid antibodies which may cause overt or subclinical hypothyroidism.

Pressure urticaria is one of the physical urticarias (others being caused by exercise, heat, cold, water exposure, sun exposure, and dermatographia). It is more common in men than women and occurs most often in 20-30 year olds (range 5-63 years).
Usually the wheals occur 30 minutes – 6 hours after the pressure and last 8 hours to 3 days. The pressure can be caused by walking, standing, sitting, carrying a handbag or groceries, using a hammer, sexual intercourse or many other activities.
Many people with pressure urticaria also have chronic urticaria. A dermographometer may be used for a pressure challenge testing to help make the diagnosis.

Learning Point
Treatment for chronic urticarias is with second-generation H1 antihistamines (e.g. loratadine, desloratadine, fexofenadine, etc.). Physical urticarias tend to respond reasonably well to second-generation H1 antihistamines. (Solar urticaria doesn’t respond as well though.)
For those that are not responding well, a combination of second-generation H1 antihistamines and H2 antihistamines (e.g. cimetidine, ranitidine, etc.), or second-generation H1 antihistamine with montelukast can be effective.
Some patients require a combination of H2 antihistamines or even systemic steroids to control their symptoms.

Questions for Further Discussion
1. What are the indications for referral to dermatology?
2. How is acute urticaria treated?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Hives and Itching
and at Pediatric Common Questions, Quick Answers for this topic: Hives

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Sciacca-Kirby J, Kim E, Levin RM, Heymann WR, Pressure Urticaria. eMedicine.
Available from the Internet at (rev. 10/2/06, cited 3/31/08).

Inettis E, Colanardi MC, Soccio AL, Ferrannini A, Vacca A.
Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule, and is effective in the treatment of delayed pressure urticaria: a randomized, double-blind, placebo-controlled study.
Br J Dermatol. 2006 Dec;155(6):1279-82.

Jauregui I, Ferrer M, Montoro J, Davila I, Bartra J, del Cuvillo A, Mullol J, Sastre J, Valero A.
Antihistamines in the treatment of chronic urticaria.
J Investig Allergol Clin Immunol. 2007;17 Suppl 2:41-52.

Huang S, Connelly KP, Windle ML, Schwartz RA, Poth MP, Jyonouchi H. Urticaria. eMedicine.
Available from the Internet at (rev. 9/21/2007, cited 3/31/08).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    May 12, 2008