Urticaria can be a debilitating condition. Patients suffer with a sometimes diffuse rash along with pruritus that can drive a person crazy. Dermatology offices are often the first referral destination for urticarial patients, but the complex issues surrounding these patients extend beneath the skin. The latest research brings insight to the underlying cause of urticarial lesions.
Getting to the bottom of acute urticaria usually involves basic medical detective work. A good history will usually lead you to the diagnosis. The most common culprits are foods (especially in children), medications and even infections. The patient usually identifies the source with a recounting of occurrences over the several hours or even days prior to the onset of the hives.
Among medications, common triggers include antibiotics like Penicillins, Cephalosporins and Sulfa-based drugs as well as over-the-counter NSAIDS or antipyretics like Advil, Alleve and aspirin. With that in mind, I check carefully in the patient’s history for meds first. Patients sometimes don’t realize that a simple antibiotic or OTC medication can cause a reaction so it’s important to ask specific questions. An infection can trigger an urticarial outbreak in highly allergic patients since they have an excess of histamine and infection facilitates the release of that histamine from skin mast cells. The treatment for acute urticaria is often simple: antihistamines for a week and avoidance of the allergic trigger.
Chronic urticaria is another story. These patients have hives that never seem to go away no matter which combination of antihistamines you throw at them. For many years, doctors tended to blame stress and psychological problems for the condition but the latest research points to an autoimmune disorder as the culprit. The mechanism of disease appears to be based in the production of autoantibody to the patient’s own IgE molecules. Just this year, the FDA approved the use of Xolair — the monoclonal antibody injection that was previously approved only for allergic asthma — for chronic urticaria. The new indication for Xolair is an exciting breakthrough for chronic urticaria as long-time sufferers may be symptom-free with just a few injections… and the results last for months!
In summary, urticaria has been a vexing condition that requires some patience on the part of both the sufferer and the physician. With good diagnostic evaluation along with advances in treatment options, the future may be looking much brighter.