eMedicine Specialties > Dermatology > Allergy & Immunology

Urticaria, Cholinergic: Treatment & Medication

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jul 1, 2009

Treatment

Medical Care

  • Sometimes, an attack of cholinergic urticaria can be aborted by rapid cooling.
  • Antihistamines, including cetirizine, are helpful for cholinergic urticaria. The response to cetirizine is important because some of the antihistaminic effect has been attributed to antimuscarinic activity.
  • UV light has been beneficial in some patients with cholinergic urticaria, but one must be circumspect about contraindications to UV light.
  • Aspirin aggravated the urticaria in 52% of patients with cholinergic urticaria, which is similar to other forms of urticaria.
  • For patients with both cold urticaria and cholinergic urticaria, ketotifen (where available) may be helpful. About 62% of patients experience a reduction in wheals, and 68% of patients report reduced itching. Cardiorespiratory symptoms also reportedly respond to ketotifen.
  • Danazol can be beneficial for patients with cholinergic urticaria, ostensibly because it elevates antichymotrypsin levels.
  • Beta-blockers, such as propranolol, have been reported to be useful in cholinergic urticaria.7
  • In evaluating any response to therapy, one must always consider that cholinergic urticaria can clear spontaneously.
  • Both topically applied benzoyl scopolamine and oral scopolamine butylbromide, where available, may be helpful in blocking the appearance of cholinergic urticaria lesions after challenge.8

Diet

  • Modifying one's diet may be helpful because cholinergic urticaria attacks can sometimes result from hot foods and beverages, highly spiced foods, and alcohol.

Medication

The goals of pharmacotherapy for cholinergic urticaria are to reduce morbidity and to prevent complications.9 Other approaches include treatment of cholinergic urticaria with anti–immunoglobulin E therapy, and combination therapy (eg, cetirizine, montelukast, and propanolol).10

Antihistamines

These agents may control itching by blocking effects of endogenously released histamine.


Cetirizine (Zyrtec)

Forms a complex with histamine for H1 receptor sites in blood vessels, GI tract, and respiratory tract.

Adult

5-10 mg PO qd

Pediatric

<2 years: Not established
2-5 years: 2.5 mg PO qd
>5 years: Administer as in adults

Increases CNS toxicity of depressants

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic or renal dysfunction; doses higher than 10 mg/d may cause drowsiness


Loratadine (Claritin)

Selectively inhibits peripheral histamine H1 receptors.

Adult

10 mg/d PO on empty stomach

Pediatric

<2 years: Not established
2-6 years: 5 mg/d PO on empty stomach
>6 years: Administer as in adults

Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Initiate therapy at lower dose in liver impairment


Desloratadine (Clarinex)

Long-acting tricyclic histamine antagonist selective for H1 receptor. A major metabolite of loratadine, which after ingestion is extensively metabolized to active metabolite 3-hydroxydesloratadine.

Adult

5 mg PO qd

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Limited data exist; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase was observed in clinically relevant adverse effects, including QTc

Documented hypersensitivity to desloratadine or loratadine

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Decrease dose in hepatic impairment; rarely causes pharyngitis or dry mouth

More on Urticaria, Cholinergic

Overview: Urticaria, Cholinergic
Differential Diagnoses & Workup: Urticaria, Cholinergic
Treatment & Medication: Urticaria, Cholinergic
Follow-up: Urticaria, Cholinergic
Multimedia: Urticaria, Cholinergic
References
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References

  1. Soter NA, Wasserman SI. Physical urticaria/angioedema: an experimental model of mast cell activation in humans. J Allergy Clin Immunol. Nov 1980;66(5):358-65. [Medline].

  2. Takahagi S, Tanaka T, Ishii K, et al. Sweat antigen induces histamine release from basophils of patients with cholinergic urticaria associated with atopic diathesis. Br J Dermatol. Feb 2009;160(2):426-8. [Medline].

  3. Moore-Robinson M, Warin RP. Some clinical aspects of cholinergic urticaria. Br J Dermatol. Dec 1968;80(12):794-9. [Medline].

  4. Confino-Cohen R, Goldberg A, Magen E, Mekori YA. Hemodialysis-induced rash: a unique case of cholinergic urticaria. J Allergy Clin Immunol. Dec 1995;96(6 Pt 1):1002-4. [Medline].

  5. Kobayashi H, Aiba S, Yamagishi T, et al. Cholinergic urticaria, a new pathogenic concept: hypohidrosis due to interference with the delivery of sweat to the skin surface. Dermatology. 2002;204(3):173-8. [Medline].

  6. Itakura E, Urabe K, Yasumoto S, Nakayama J, Furue M. Cholinergic urticaria associated with acquired generalized hypohidrosis: report of a case and review of the literature. Br J Dermatol. Nov 2000;143(5):1064-6. [Medline].

  7. Ammann P, Surber E, Bertel O. Beta blocker therapy in cholinergic urticaria. Am J Med. Aug 1999;107(2):191. [Medline].

  8. Tsunemi Y, Ihn H, Saeki H, Tamaki K. Cholinergic urticaria successfully treated with scopolamine butylbromide. Int J Dermatol. Oct 2003;42(10):850. [Medline].

  9. Feinberg JH, Toner CB. Successful treatment of disabling cholinergic urticaria. Mil Med. Feb 2008;173(2):217-20. [Medline].

  10. Metz M, Bergmann P, Zuberbier T, Maurer M. Successful treatment of cholinergic urticaria with anti-immunoglobulin E therapy. Allergy. Feb 2008;63(2):247-9. [Medline].

  11. Czubalski K, Rudzki E. Neuropsychic factors in physical urticaria. Dermatologica. 1977;154(1):1-4. [Medline].

  12. Fukunaga A, Bito T, Tsuru K, et al. Responsiveness to autologous sweat and serum in cholinergic urticaria classifies its clinical subtypes. J Allergy Clin Immunol. Aug 2005;116(2):397-402. [Medline].

  13. Hirschmann JV, Lawlor F, English JS, et al. Cholinergic urticaria. A clinical and histologic study. Arch Dermatol. Apr 1987;123(4):462-7. [Medline].

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  15. Khakoo G, Sofianou-Katsoulis A, Perkin MR, Lack G. Clinical features and natural history of physical urticaria in children. Pediatr Allergy Immunol. Jun 2008;19(4):363-6. [Medline].

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  17. Mihara S, Hide M. Adrenergic urticaria in a patient with cholinergic urticaria. Br J Dermatol. Mar 2008;158(3):629-31. [Medline].

  18. Nakazato Y, Tamura N, Ohkuma A, Yoshimaru K, Shimazu K. Idiopathic pure sudomotor failure: anhidrosis due to deficits in cholinergic transmission. Neurology. Oct 26 2004;63(8):1476-80. [Medline].

  19. Tupker RA, Doeglas HM. Water vapour loss threshold and induction of cholinergic urticaria. Dermatologica. 1990;181(1):23-5. [Medline].

  20. Warin R, Champion R. Urticaria. Philadelphia, Pa: WB Saunders; 1974:136-44.

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Further Reading

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Keywords

urticaria, cholinergic urticaria, heat-induced urticaria, sweat-induced urticaria, micropapular urticaria, stress-induced urticaria

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Mark G Lebwohl, MD, Chairman, Department of Dermatology, Mount Sinai School of Medicine
Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Abbott Laboratories Honoraria Consulting; Actelion Honoraria Consulting; Amgen Honoraria Consulting; Astellas Honoraria Consulting; Centocor Honoraria Consulting; DermiPsor Honoraria Consulting; Galderma  Consulting; Genentech Honoraria Consulting; Helix BioMedix Honoraria Consulting; Medicis Honoraria Investigator

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Christen M Mowad, MD, Associate Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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