Ask the Pharmacist

Q) I keep getting these breakouts of raised red swellings on my skin that are extremely itchy but go away on their own a few hours later. My doctor sent me to a specialist in allergies who told me I have chronic spontaneous urticaria. What is that and what does it mean for me?

A) Chronic urticaria (known as CU and also sometimes referred to as idiopathic urticaria) is a skin condition that can be extremely stressful for those who are diagnosed with it. These people tend to get repeated episodes of hives or “wheals” on their skin often without warning.

Hives affect about 20% of Canadians at some point in their lives but for most of us, they are a temporary allergic reaction to something that we have inhaled (pollens, mold, animal dander..), injected (insect bites or stings or medications) or ingested (foods, food additives like MSG or drugs) that may never again reoccur. For an unfortunate few, these unpleasant reactions are far from transient.

Urticaria (which is essentially another word for hives) is deemed chronic when the symptoms spontaneously re-occur daily or almost daily for at least 6 weeks. It’s an uncommon condition but not exceedingly rare as it afflicts somewhere between 0.5 to 1.2% of the world’s population. Women are more than twice as likely to be diagnosed as men and most people are diagnosed between the ages of 20 and 40.

Hives appear as swellings on the skin that are sometimes pink or red (but occasionally have no abnormal colouration) and are surrounded by a red blotch. They are typically either round or oval and vary in size but may blend together to form larger areas of swelling. While they may appear anywhere on the skin, the trunk, thighs, upper arms and face are most commonly impacted by them. They are usually quite itchy and sometimes can be quite painful as well.

For most they fade within 8 to 12 hours but those with CU can expect to see them again within the next 24 to 72 hours and this condition generally lasts for 1 to 5 years for most people with CU. Unfortunately, for an unlucky minority, it is not uncommon for it to go on indefinitely (10-50% will have this condition last longer than 5 years).

Along with the typical skin symptoms those who have been diagnosed with CU typically also are more likely to be sleep deprived, struggle with depression and anxiety and feel more socially isolated than the general population does.

Experts believe that the whole process starts with a sensitizing allergen (such as a pollen or in 30-50% of CU flare-ups the ingestion of an NSAID such as ibuprofen) binding to one of our antibodies known as IgE. This complex in turn binds to mast cells that are circulating around which causes these cells to release histamine and a bunch of inflammatory chemicals into our surrounding tissues leading to the swelling, redness and itchiness.

For some people with CU, the condition can be triggered or induced by their environment whereas others find the condition occurs without seeming to follow any pattern. This allows us to classify the urticaria based upon the trigger. For those with no apparent determining cause, the condition is classified as chronic spontaneous urticaria. Others have what is termed inducible urticaria.

These urticarias are classified by their triggers and include cold urticaria (triggered by cold air or ice), solar urticaria (mainly affecting areas of the skin that get exposed to the sun that don’t usually receive much sun exposure…) heat urticaria (triggered by a hot drink or hot water bottle), dermagraphoism (caused by scratching or tight clothing), cholinergic urticaria (by increased body heat due to exercise, emotional upset or a hot shower), contact urticaria (where an allergen touches the skin such as with latex), and delayed pressure urticaria (resulting from pressure on the affected area several hours earlier such as from a seat belt or sitting).

Treatment for any of these different classes starts with the use of second generation antihistamines (think Reactine/ ceterizine or Aerius/ deslorartidine or Allegra/ fexofenadine) much the same as we treat seasonal allergies. Note that Benadryl/ diphenhydramine or chlorphenirmine are not mentioned here. New international guidelines for the treatment of both allergies and urticaria no longer recommend these older antihistamines because of their many drug interactions, their interference with REM sleep (which is delayed and reduced while on these) and their impairment of both cognitive function and motor reflex time which can obviously impact both working and driving.

The usual doses of the 2nd generation antihistamines are tried on their own for a period of 2 to 4 weeks to allow time for them to reach full effectiveness. If the urticaria has failed to respond by then and the drug is well tolerated, the dose can be increased up to 4 times the usual recommended amount (e.g. 40mg cetirizine or 20 mg of desloratidine) safely with the only typical downside being an increased chance that the drug may make you drowsy.

There are two newer prescription only type antihistamines (bilastine or rupatadine) that would also be suitable. Patients who have failed to improve adequately after 2 to 4 weeks at these higher doses could be tried on the injectable monoclonal antibody drug known as Xolair/omalizumab. This injection is given every 2-4 weeks and works well for some people but does have some potential for significant side effects so its use warrants a good discussion with your specialist.

The last option that can be added on to these drugs is the immune suppressant cyclosporine (which has been used for years in transplant patients) which could be considered after six months of Xolair therapy and only under the supervision of a specialist once again.

Urticaria can be a maddening disorder for those who suffer from it but there are effective treatments out there and, along with trigger avoidance (when possible), can help patients maintain an excellent quality of life. For more information about this or any other health related questions, contact your pharmacist.