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Chronic Spontaneous Urticaria From Diagnosis to Treatment: Unique Perspectives on Employing a Multidisciplinary and Patient-Centric Approach to Care
The document outlines a diagnostic and treatment approach for chronic spontaneous urticaria (CSU), detailing various symptoms and differential diagnoses. It presents a stepwise treatment algorithm including different medication options such as antihistamines, omalizumab, and cyclosporine A, depending on the severity of the condition. Additionally, it encourages patients to track their symptoms for better management and to assess treatment response.
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Chronic Spontaneous Urticaria From Diagnosis to Treatment: Unique Perspectives on Employing a Multidisciplinary and Patient-Centric Approach to Care
- 1. Diagnostic Approach toChronic Spontaneous Urticaria1-6 Full abbreviations, accreditation, and disclosure information available at PeerView.com/KXJ40 Wheals Angioedema Recurrent unexplained fever? Joint/bone pain? Malaise? ACE inhibitor treatment? Autoinflammatory disease? Average wheal duration >24 h? HAE or AAE? Remission after stop? Provocation test Acquired/ hereditary AID Urticarial vasculitis CSU Chronic inducible urticaria HAE I-III AAE ACE inhibitor– induced AE History Histamine and other mast cell mediators Interleukin-1 Bradykinin +- +- +-+ - + - +- +- + - + - DiagnostictestsTreatment EAACI/GA²LEN/EDF/WAO Recommended Diagnostic Algorithm for Chronic Urticaria Signs of vasculitis in biopsy? Are symptoms inducible?
- 2. Diagnostic Approach toChronic Spontaneous Urticaria1-6 Full abbreviations, accreditation, and disclosure information available at PeerView.com/KXJ40 1. Zuberbier T et al. Allergy. 2018;73:1393-1414. 2. Schaefer P. Am Fam Physician. 2011;83:1078-1084. 3. Bernstein JA et al. J Allergy Clin Immunol. 2014;133:1270-1277. 4. Kahan S, Smith EG. In a Page: Signs and Symptoms. Malden, MA: Blackwell Publishing; 2004. 5. Katelaris C, Peake J. Med J Aust. 2006;185:517-522. 6. Hong-feng C et al. Chinese External Medicine. Beijing, China: People’s Medical Publishing House; 2011. CSU: Clinical Presentation and Differential Diagnosis Papular urticaria from arthropod bites • Pruritic • Individual lesions may last several days to several weeks Eczema • Maculopapular, scaly, and pruritic • Individual areas of involvement; typically lasts weeks or more Erythema multiforme • Iris-shaped papules; target appearance • May have fever; joint pain • Lesions last several days; pruritic Urticarial vasculitis • Individual wheals that last for >24 hours, are painful, and leave residual hyperpigmentation or purpura CSU • Edematous pink or red wheals of variable size and shape with surrounding erythema; generally pruritic • Individual urticarial lesions typically last 12-24 hours but new lesions might be developing simultaneously at other skin sites Cutaneous mastocytosis • Orange to brown hyperpigmentation of the lesions that remain • Darier sign: urtication upon scratching over lesions; assumes no dermatographism
- 3. EAACI/GA²LEN/EDF/WAO Recommended Stepwise TreatmentAlgorithm for Urticaria1,2 Full abbreviations, accreditation, and disclosure information available at PeerView.com/KXJ40 a The leukotriene receptor antagonists (especially montelukast) can be used as an add-on therapy but is not recommended by the EAACI/GA²LEN/EDF/WAO guideline. 1. Zuberbier T et al. Allergy. 2018;73:1393-1414. 2. Xolair (omalizumab) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/103976s5234lbl.pdf. Considerspecialistreferral Shortcourseofcorticosteroidsincaseofexacerbations Shouldbeperformedunder supervisionofaspecialist Fourth-line treatment Add-on to second-generation H1 -receptor antihistamine: cyclosporine A Control inadequate after 2-4 weeks or earlier if symptoms are intolerable Control inadequate after 2-4 weeks or earlier if symptoms are intolerable Control inadequate within 6 months or earlier if symptoms are intolerable First-line treatment Second-generation H1 -receptor antihistamine Second-generation H1 -receptor antihistamines commonly used in United States (adult dosing) • Cetirizine: 10 mg daily • Levocetirizine: 5 mg daily • Desloratadine: 5 mg daily • Loratadine: 10 mg daily • Fexofenadine: 180 mg daily Second-line treatment Increase dose of the second-generation H1 -receptor antihistamine up to fourfolda Third-line treatment Add-on to second-generation H1 -receptor antihistamine: omalizumab injected subcutaneously every 4 weeks (150 or 300 mg)
- 4. Chronic Spontaneous Urticaria(CSU) for Patients: Keeping Track of Symptoms Full abbreviations, accreditation, and disclosure information available at PeerView.com/KXJ40 1. Zuberbier T et al. Allergy. 2018;73:1393-1414. 2. Goldstein S et al. Acta Derm Venereol. 2019;99:1091-1098. Fourth-line treatment Add-on to second-generation H1 -receptor antihistamine: cyclosporine A Wheals (number) 0 = none 1 = 0-20 wheals 2 = 20-50 wheals 3 = ≥50 wheals Daily UAS (0-6) Weekly UAS7 (0-42) Itch (severity) 0 = none 1 = mild 2 = moderate 3 = severe Once dailyOnce daily Sum for 7 days This tool can be used to track your changing symptoms over time Managing Your Symptoms Keeping track of symptoms can help you and your doctor measure the severity of your CSU and monitor your response to treatment The Urticaria Activity Score (UAS7) allows you to measure the severity of your itch and hives How much do your hives itch? CSU is defined by the presence of recurrent urticaria (also called hives or wheals), angioedema, or both, for a period of 6 weeks or longer1 People with CSU feel they don’t have control of their symptoms2 How much of your body is affected? How many hives do you have? How is your daily life affected?