At the 2020 Winter Clinical Dermatology Conference, Mark Lebwohl, MD, addressed updates in the care of chronic urticaria in Hawaii. Between diagnosis and treatment options, attendees learned new tricks and tips for management.
Distinguishing physical urticaria from urticarial vasculitis can be easy when dermatologists consider the clinical signs. Chronic, physical urticaria lasts less than 24 hours in any one place on the body and often itches, whereas urticarial vasculitis is often painful and can last for weeks in a single place. Notably, autoimmune diseases, such as hyperthyroidism and hypothyroidism, Celiac disease, and Sjögren syndrome, are more prevalent in patients with chronic urticaria.
Interestingly, diet plays no role in the management of urticaria. Patients often present with anecdotes of improvement of their urticaria when they eliminate certain foods from their diets, but the literature has not shown improvement. The only possible dietary change that may occur in the presentation of urticaria angioedema, noted Dr Lebwohl, following the bite of a Lonestar tick, which can induce a red meat allergy through the transmission of alpha-gal antibodies.
A number of treatment options for chronic urticaria exist, but as Dr Lebwohl discussed, many of them are relatively ineffective or unsupported in the literature, including narrowband UV-B therapy, methotrexate, tacrolimus, warfarin, eradication of Helicobacter, sulfasalazine, among others.
Dr Lebwohl did highlight several therapies that have found relative success in the treatment of chronic urticaria. For example, systemic corticosteroids can be an effective option. This option carries the normal associated risks of systemic treatment and should be initiated with extreme caution.
Next, Dr Lebwohl mentioned antihistamine H1 as an effective option. “If you look at the antihistamines, you have to up the dose,” he said. In one 2010 study from the Journal of Allergy and Clinical Immunology, 75% of refractory patients with urticaria responded to a higher dose of antihistamines. “My favorite one, because it doesn’t make you sleepy even if you up the dose dramatically, is fexofendadine, which is Allegra over-the-counter,” continued Dr Lebwohl. He explained that fexofendadine can be used up to four times a day without side effects.
Two other effective options are cyclosporine and mycophenolate. “Cyclosporine clearly works,” said Dr Lebwohl, and he continued to explain that his usual dosage of mycophenolate is 4000 mg per day, though the literature has shown doses as high as 6000 mg per day.
Omalizumab (Xolair) has demonstrated great success for the various phenotypes of urticaria (autoimmune, non-autoimmune, chronic spontaneous, recalcitrant physical, angioedema, antihistamine-refractory). A 300-mg dose can be administered, but dermatologists should make patients aware that the therapy can take about 5 days to take effect. While mild to moderate treatment-emergent adverse effects, including headache, arthralgia, and injection site reactions, have been documented, omalizumab is well-tolerated and safe.
However, Dr Lebwohl emphasized, many dermatologists seem to fear the black box warning associated with biologics. “The number [for anaphylaxis frequency] is 0.2%, but why is that?” he said. “Well, [omalizumab] is treating the symptoms of anaphylaxis. You’re treating wheezing, you’re treating urticaria, angioedema, and it doesn’t work for a few days…so patients could blame the injection for the symptoms they’ve had all along.”  So, omalizumab’s potential side effects may not be as big a deal as the dermatology field fears.
With use of omalizumab, urticaria can recur after a median of 5 weeks, so Dr Lebwohl has patients come back every 4 weeks for a maintenance dose. After 6 months, he suggested making a quick scratch on the patient’s arm; if the patient does not get dermographism, then the injection can be delayed as spontaneous remission may have occurred.
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Reference
"Lebwhol M. Chronic urticaria update. Presented at: 2020 Winter Clinical Dermatology; Kohala Coast, HI; January 19, 2020.
