Treatment of Chronic Urticaria Check this out!!!

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Treatment of Chronic Urticaria

H. Epstein: Therapy of chronic urticaria is frequently frustrating and unsuccessful. Because of this, let us ask for the opinions of Dr. Harry Roth (University of California, San Francisco). Then, we ask Dr. L. Epstein to question Dr. Lennart Juhlin (University Hospital Nijmegen), and Dr. Alain Claudy (University of Lyon) on this topic.

Harry L. Roth: Consider each case to be due to an "antigen," and continue looking until the urticaria is gone. Even then, the etiology of chronic urticaria is found in only 20-25 percent of cases studied. The following techniques may be employed in eliciting the cause of chronic urticaria. l. Empirical dietary control with elimination diets up to two weeks a. All salicylates b. All tartrazines -- food colorings and many drugs contain these, so read the PDR and all labels c. Candida and other yeasts (1) Low yeast diet: Eliminate bread, buns, sausage, wine, beer, cider, grapes, cheese, vinegar, ketchup, pickles, yeast tablets, and canned foods with yeast. (2) Use Nizoral or Diflucan for one to two weeks as trial (3) May do prick test for Candida antigen, or may do oral challenge to Baker's yeast d. Preservatives, e.g., benzoates and aminobenzoic acid e. Sulfites - in wines, as vegetable color enhancer, in drugs, e.g., Gantrisin f. Butylate hydroxytoluene (BHT), found in chewing gum, potato chips, peanuts, and cake mix g. Seafoods (lobster, scallops) contain tyramine, a powerful histamine-liberator; also, tyramine produced by foods altered by yeast or molds h. Dietary regimens with elimination of: milk, citrus, chocolate, cola, cinnamon, tomatoes, fish, strawberries, peanuts, peas, beans, eggs, pork, nuts, wheat, artificial food colors. 2. If RAST or scratch tests are done, check molds -- especially in farm workers, hunters, or construction workers. Check pollens, house dust, and animal epidermals a. Food diary -- list meals, snacks, and times of flares b. Eliminate and check for cinnamic aldehyde or acid, benzoic acid, menthol, or wintergreen 3. Elimination of focus of infection a. Teeth and periodontal b. Sinusitis c. Gallbladder d. Rarely tinea or onycholysis e. Intestinal infection with parasites, Campylobacter jejuni, or Giardia f. Bladder, kidney, prostate 4. Therapeutic trials, especially: a. Diflucan or Nizoral x 14 days b. Tetracycline hydrochloride 500 mg b.i.d. x 14 days c. Cipro 500 mg b.i.d. x 10 days d. Azulfidine 500 mg q.i.d. x 5 days e. Chloroquine (see PDR for dosing) f. Flagyl 250 mg t.i.d. for 7 days g. Thiabendazole 25 mg/kg b.i.d. for 4 days h. Lamisil 250 mg b.i.d. for one week/per month in pulse dosing; may repeat for four months for onycholysis i. Dapsone 100 mg b.i.d. for 7 days for dermatitis herpetiformis or PMN-rich infiltrate of urticaria j. Scabies in differential diagnosis, treat with Kwell or Elimite 5. Antihistamines a. Claritin 10 mg b.i.d. b. Zyrtec 10 mg 1-3x per day c. Allegra 60 mg b.i.d. d. Doxepin -- increase dose to 150 mg h.s. as tolerated e. Periactin 4 mg q.i.d. 6. Non-Antihistamines a. Cimetidine 300 mg q.i.d. for H2 receptor-caused urticaria. May be used in conjunction with H1 blockers b. Theophylline c. Ephedrine d. Terbutaline 1.25-5 mg t.i.d. 7. Cautious trials of inducing tolerance to causes of physical urticaria, e.g. graded introduction to heat, cold, water by frequent exposures and observing patients for untoward effects 8. Solar urticaria may be treated by incremental suberythema doses of UVA with Ultra Oxpsoralan 0.6 mg/kg three times per week for eight weeks, and then maintain by outside exposure to normal sunlight a. Also use high doses of beta carotene in solar uriticaria b. Adrenergic urticaria can be treated with Inderal 20 mg t.i.d. Q1by WLE: Malcolm Greaves had given a paper at the World Congress of Dermatology in which he described an autoantibody against the high affinity IgE receptor of mast cells and basophils that is unique in its ability to stimulate the normal function of mast cells. What do you think of the possibility that a chemotherapeutic agent with a good safety profile be developed which will surpass classic histamine receptor blockers A1 from LJ: In a certain percentage of patients, autoantibodies exist. A simple test is to inject the patients own serum i.c. and look for the wheal reaction coming after 2-8 hours. It is possible that safe drugs could surpass the antihistamines in the future, but at present, immunosuppressants can not be recommended like cyclosporin or immunoglobulin i.v. (BJD 138.101, 1998). from AC: I am looking for a chemotherapeutic agent able to surpass classic histamine blockers. Q2 by WLE: As the s proposed; Do you do a series of therapeutic trials with such drugs as antibiotics or antifungals? If so, for how long? Do you use antimetabolites? A2 from LJ: The Helicobacter story with good effects of antibiotics and omeprazol (Losec) cannot be neglected and can have one explanation. If it is necessary that the patient has a Helicobacter positive test or gastric symptoms is not clear, but it certainly works in those who have it. We use drugs against Candida but not antimetabolites. from AC: No Q3 by WLE: What percent of your patients with chronic urticaria have atopy? A3 from LJ: The figures we published in Brit. J. Derm. 104.1372, 1981 seem to be the same. Here, physical uriticarias were first removed and we talked about chronic "idiopathic" urticaria, rhinitis and asthma were most common, respectively, in 11 percent. Earlier published results were revised. from AC: 15% Q4 by WLE: If the patients with urticaria have atopy, do you subsribe to the idea that this is a T-2 type of immunologic response (ie allergy)? A4 from LJ: T-2 type responses can be possible in some. from AC: Yes Q5 by WLE: What is your approach to therapy? How does it differ from what Dr. Roth outlined, and specifically, do you think topical analgesics or other therapies really help in chronic urticaria? A5 from LJ: A. We use UV-B irradiation to decrease the sensitivity and need for antihistamines. B. We rarely use sedating antihistamines like Doxepin and Periactin. C. I prefer to increase the dose of Claritin or Zyrtec if the patient is over 60 kg body wt. to 20 mg/day instead of trying a H2 blocker. D. I have been disappointed with the effect of Terbutalin and I don't use Lamisil for urticaria if they only have onychomycosis. E. Omeprazol and amoxicillin probably are worth trying more in the future. F. These are my main points about the excellent guidelines by Dr. Roth. Important also is to continually have a dialogue with the patient and be curious about rare causes. I think we can do better than just waiting for the natural disappearance which can take years. from AC: I usually prescribe antihistamines, but no topical analgesics or other therapies Q6 by WLE: Have you tried or what do you think of the ideas of topical or systemic immunosuppressive drugs ? A6 from LJ: from AC: I never tried systemic immunosuppressive drugs in chronic urticaria, but would be interested to test a topical immunosuppressive drug with a good safety profile.

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