Chronic Idiopathic Urticaria Treatment Guidelines

October 19, 2020     

Urticaria is the medical name for hives. These are red, itchy bumps or bumps on your skin often accompanied by an allergic reaction or sometimes a viral infection. Urticaria can be very uncomfortable, affecting sleep and normal daily activities. Or sometimes, it can get worse if it occurs with a severe allergic reaction called anaphylaxis. There is a condition called chronic idiopathic urticaria. To put it simply, that means a hive lasts longer than six weeks for no apparent reason. Many people call it CIU. About 1.5 million people in India have it. However, for a few people, hives keep reappearing for no apparent reason. If a new outbreak occurs nearly every day for six weeks or more, it is called chronic idiopathic urticaria (CIU). 

Before classifying hives as idiopathic, your doctor will check for any allergies or infections. If none of them is the cause, it could be idiopathic urticaria. About 75 per cent of urticaria cases are idiopathic.

Chronic hives are not an immediate risk. However, a sudden onset of hives can sign an allergic reaction that can lead to anaphylactic shock. This is a severe condition that can close the throat and cause choking. Use an EpiPen (adrenaline injecting device) if available and seek emergency help immediately if this happens to you.

This article provided by Cosmosure Clinic will help you with the treatment for chronic idiopathic urticaria. 

What is urticaria?

Urticaria is a skin condition characterized by redness (hives) or angioedema (swelling in 10%) or both (40%). There are different types of urticaria.

• Weal is a superficial discolouration of the skin or pale swelling of the skin that is usually surrounded by erythema (redness) and lasts from a few minutes to 24 hours. Generally very itchy, there may be a burning sensation.
• Angioedema is deep swelling of the skin or mucous membranes and can be skin-coloured or red. It disappears in 72 hours. Angioedema can be itchy or painful but is often asymptomatic.

What Is Chronic Urticaria?

In Chronic urticaria, people experience daily or episodic weal or angioedema for more than six weeks. Chronic urticaria can occur spontaneously or be induced. These two types can coexist.

Induced or physical urticaria is classified according to the stimulus that causes healing.

Symptoms

 Signs and symptoms of chronic hives include:

• Lots of red coloured skin (pimples) that can appear anywhere on the body
• Welts, which vary in size, change shape and appear and repeatedly fade as the reaction progresses.
• Itching, which can be severe
• Painful swelling is known as Angioedema of the lips, eyelids, and throat.
• The tendency to show signs and symptoms with triggers such as heat, exercise, and stress
• The tendency for signs and symptoms to last for more than six weeks and to be frequent and unpredictable, sometimes for months or years

Short-term (acute) hives occur suddenly and go away within a few weeks.

Causes of CIU:
The weal associated with hives occurs when specific cells release histamine and other chemicals into the bloodstream. Often, doctors cannot identify the cause of chronic hives or why acute hives are sometimes a long-term problem. Skin reactions can be 

caused by:

• Painkiller
• Insects or parasites
• Infection
• Scratching
• Hot or cold
• Stress or anxiety 
• Sunlight
• Sports
• Alcohol or food
• Pressure on the skin. It is common if you use tight waistbands.

In some cases, chronic urticaria can be associated with an underlying condition such as thyroid disease or, rarely, cancer.

When to see a doctor

Call your doctor if you experience severe hives or hives that persist for several days. Chronic urticaria does not pose the risk of a severe allergic reaction (anaphylaxis) suddenly. If you develop urticaria as part of a severe allergic reaction, go to the doctor immediately. Signs and symptoms of anaphylaxis include 

• Dizziness
• Difficulty in breathing
• Swelling of the lips, eyelids, and tongue.

How is chronic urticaria diagnosed?

Chronic urticaria is diagnosed in people with a long history of a diurnal or episodic illness. It lasts less than 24 hours, with or without angioedema. Family history needs to be extracted. A thorough physical examination must be carried out to assess the cause. Inducible urticaria is often caused by scratching the skin with dermographism or applying ice cubes in case of cold urticaria.

Only diagnostic tests for chronic spontaneous urticaria are blood count and C-reactive protein (CBC, CRP) test. However, tests can be done if an underlying condition is suspected.

• An autologous serum skin test is sometimes performed for chronic spontaneous urticaria, but the value is uncertain. Positive if injecting the patient’s serum under the skin causes redness.
• Tests for systemic conditions or inflammatory disease alone should be performed in urticaria patients with fever, joint or bone pain, and malaise.
• Patients with untreated angioedema should be asked if they are taking an ACE inhibitor and tested for C4 complement. C1-INH Level, Function, and Antibody; and C1q.
• An urticaria biopsy can be nonspecific and difficult to interpret. Pathology reveals swelling of the dermis and dilated blood vessels with a variable mixed inflammatory infiltrate. Lesions on the vessel wall suggest urticarial vasculitis.

Treatment of CIU:

The goals of treatment are:

• Relief from itching
• Make the hive more bearable.
• Give full resolution to your hive.

Your doctor will likely recommend that you manage your symptoms with home remedies, such as over-the-counter antihistamines. If self-care measures don’t help, talk to your doctor about finding a prescription medication or drug combination that works best for you. Effective treatments can usually be found.

Antihistamines: Taking a non-drowsy antihistamine every day will help block histamine release. Examples include:

• Loratadine (Claritin)
• Fexofenadine (Allegra)
• Cetirizine (Zyrtec)
•  Desloratadine (Clarinex)

If a non-drowsy antihistamine doesn’t help, your doctor may increase the dose or try the kind that usually puts people to sleep and take it before bed. Talk to your doctor before taking this medication if you are pregnant or breastfeeding, have a chronic disease or are taking other medications.

Other medications include:

If antihistamines alone don’t relieve your symptoms, other medications can help. As an example:

• Histamine (H-2) inhibitors: These medicines, also called H-2 receptor antagonists, are either injected or taken orally. Examples are cimetidine (Tagamet HB) and famotidine (Pepcid).
• Anti-inflammatory drugs: Oral corticosteroids such as prednisone can reduce swelling, redness, and itching. They are usually used to treat severe itching or angioedema in the short term, as long-term use can cause serious side effects.
• Antidepressants: The tricyclic antidepressant Doxepin (Zonalon), used as a cream, can help relieve itching. This medicine may cause dizziness and drowsiness.
• Asthma medication with antihistamines: Medicines that interfere with leukotriene-converting action are useful when used along with antihistamines. Examples are Montelukast 
• Human-made (monoclonal) antibodies: Omalizumab (Xolair) is very effective against chronic types of hives, challenging to treat. This is an injectable drug that is usually given once a month.
• Immunosuppressants: Options include cyclosporine (Gengraf, Neoral, others) and tacrolimus (Astagraf XL, Prograf, Protopic).

Avoiding triggers: 

Chronic hives can last for months and years and interfere with work, sleep, and other activities. The following precautions can help reduce recurrent skin reactions caused by chronic hives:

• Treat any identified chronic infections such as H. pylori.
• Avoid aspirin, opiates, and nonsteroidal anti-inflammatory drugs (paracetamol is usually safe).
• Minimize food pseudo allergens during the trial period of at least three weeks.
• Avoid known allergies confirmed by a positive IgE / skin prick test if they are clinically relevant to urticaria.
• Use a fan, cool flannel, ice pack, or soothing, moisturizing lotion to cool the affected area.
• Wear loose, light clothing.
• Avoid scratching or using raw soap.
• Soothe the affected area with a bath, ventilator, cool towel, anti-itch lotion, or cream.
• Keep a journal about when and where the hives appear, what you do, what you eat, etc. This can help you and your doctor identifies the cause.
• Avoid certain triggers.
• Apply sunscreen before going outside.

Some patients with CIU use daily symptom induction to induce tolerance. Phototherapy can be useful for symptomatic dermographism.

Try to change your diet:

Common foods that cause allergies in some people include eggs, shellfish, peanuts, and other nuts. Rotten fish can be high in histamine, which can cause hives. If you or your doctor suspect hives are from a food allergy, tests can be done to check for them. You may be asked to keep a journal of everything you eat and drink.

Dietary supplements and salicylic acid (found in aspirin) have been shown to cause urticaria in some people. Aspirin and other non-steroidal anti-inflammatory drugs have been reported to worsen the onset of urticaria in 20 to 30 per cent of people with chronic urticaria.

Conclusion:

Chronic idiopathic urticaria is an uncomfortable, but not life-threatening, condition. Treatment with antihistamines or other drugs will usually eliminate this. But it can come back if treatment is stopped.

You should see your doctor if you have severe urticaria or if it lasts for several days. For more information, contact Cosmosure Clinic at 040 4953 0404 for the Best treatment of CIU. Book your appointment now.