Pressure Urticaria Treatment & Management

Updated: Aug 08, 2016
  • Author: Sarah Beggs, MD; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Approach Considerations

Patients should attempt to limit pressure stimuli. A simple intervention is to broaden the handles on heavy items or straps on clothing to disperse the pressure over a larger area. However, avoidance is not easy and may not be helpful in patients with moderate-to-severe disease.

The results of pharmacologic treatment of delayed pressure urticaria (DPU) are somewhat disappointing. Second-generation antihistamines are first-line treatment. Second- and third-line agents include systemic corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, dapsone, sulfasalazine, montelukast, chloroquine, cyclosporine, intravenous immunoglobulin (IVIg), omalizumab, and anakinra.

Restrictions in activity depend on the severity of the disease. Consult a dermatologist or allergist for evaluation for other causes of urticaria.

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Pharmacologic Therapy

Second-generation antihistamines can reduce the severity of symptoms of swelling frequency and severity and are helpful in controlling associated chronic idiopathic urticaria (CIU), but they may not control the symptoms completely. Some authors have used up to four times the recommended dose of nonsedating antihistamines to achieve control. [26]

NSAIDs produce variable responses. As treatment, they may be suboptimal because they, along with aspirin, may worsen urticaria and angioedema. Indomethacin has not demonstrated efficacy in the treatment of delayed pressure urticaria (DPU).

Steroids are best restricted for recalcitrant and severe DPU. Prednisone has some clinical efficacy, but long-term therapy is problematic because of its many adverse effects. One study of a small group of patients found high-potency topical steroids to be efficacious for reducing edema, erythema, and pruritus associated with DPU lesions. [28] Patients who see improvement with systemic steroid therapy often relapse when these agents are discontinued. The adverse effects of steroids must also be considered and managed. [29] Methotrexate has been used successfully in steroid reduction in a few patients with steroid-dependent DPU. [30]

Omalizumab, a recombinant DNA monoclonal antibody that binds to IgE, is showing beneficial results in CIU, owing to its ability to decrease mast cell degranulation. Three phase 3 clinical trials, ASTERIA I, ASTERIA II, and GLACIA, involving over 900 patients with chronic spontaneous urticaria showed the benefits of omalizumab. [30] A phase 3, multicenter study has shown omalizumab to decreased itchiness and hives and increase quality of life (QOL) in patients with CIU or chronic spontaneous urticaria, who had been refractory to antihistamine therapy. [31] Patients, including those with DPU, who initially had a positive response to omalizumab, and then relapsed after stopping treatment, achieved remission after restarting omalizumab. [32] Multiple case reports have reported the benefit of omalizumab treatment in patients with DPU. This potentially could be excellent treatment for DPU, although it is currently only US Food and Drug Administration (FDA) approved for chronic spontaneous urticaria. [33]

Other therapeutic agents that have been tried include colchicine, dapsone, sulfasalazine, and montelukast. [34, 35] Colchicine has been largely ineffective as a therapy. Dapsone has demonstrated beneficial results persisting after treatment in a small study. [36] A 2015 case series showed that in 17 patient treated with sulfasalazine, 11 had complete or near complete resolution and four had a partial response. [37] Reports from small studies have found leukotriene antagonists, alone or in combination, to be efficacious for the treatment of DPU [8] ; other forms of chronic urticaria have not demonstrated similar responses to this treatment. Case reports have demonstrated successful treatment with chloroquine, cyclosporine, IVIg, tricyclic antidepressants, selective serotonin reuptake inhibitors, and anakinra have each been used in a small number of patients with relative success. [38, 39, 40, 41, 42, 43]

Combination therapy may decrease disease activity. Adjunctive agents that reportedly have been successfully used in this context include leukotriene antagonists (eg, montelukast, zafirlukast) and H2-receptor antagonists (eg, famotidine, ranitidine). [44]

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