Pressure Urticaria Treatment & Management

  • Author: Joslyn S Kirby, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 25, 2011
 

Medical Care

  • 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.
  • Antihistamines can reduce the severity of symptoms and are helpful in controlling associated chronic idiopathic urticaria (CIU).
  • Systemic corticosteroids and/or nonsteroidal anti-inflammatory drugs (NSAIDs) produce variable responses. Patients with improvement with systemic steroids often relapse upon discontinuation. The adverse effects of steroids must also be considered and managed. Patients may already be taking H2 blockers in an attempt to manage their urticaria; however, these are also used to treat gastritis from systemic steroids. Long-term steroid use also affects the bones, and patients are often advised to take calcium with vitamin D daily, with additional consideration of adding a bisphosphonate such as alendronate.[21]
  • Other possible therapies include colchicine, dapsone, sulfasalazine, and montelukast.[22, 23] Case reports have demonstrated successful treatment with chloroquine.[24]
  • Cyclosporine, intravenous immunoglobulin, and omalizumab have each been used in a small number of patients with severe and refractory disease.[25, 26, 27]
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Consultations

Consult a dermatologist or allergist for evaluation for other causes of urticaria.

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Activity

Restrictions in activity depend on the severity of the disease.

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Contributor Information and Disclosures
Author

Joslyn S Kirby, MD  Assistant Professor, Department of Dermatology, Milton S Hershey Penn State Medical Center

Joslyn S Kirby, MD is a member of the following medical societies: American Academy of Dermatology, International Society for Cutaneous Lymphomas, Pennsylvania Academy of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ellen J Kim, MD  Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania

Ellen J Kim, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Dermatology Foundation, Medical Dermatology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Robin M Levin, MD  Staff Physician, Assistant Professor, Department of Family Medicine, Division of Dermatology, Kennedy Hospital at Stratford

Robin M Levin, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Warren R Heymann, MD  Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel J Hogan, MD  Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M 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, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Barlow RJ, Warburton F, Watson K, Black AK, Greaves MW. Diagnosis and incidence of delayed pressure urticaria in patients with chronic urticaria. J Am Acad Dermatol. Dec 1993;29(6):954-8. [Medline].

  2. Commins SP, Kaplan AP. Immediate pressure urticaria. Allergy. Jan 2002;57(1):56-7. [Medline].

  3. Lawlor F, Black AK. Delayed pressure urticaria. Immunol Allergy Clin North Am. May 2004;24(2):247-58, vi-vii. [Medline].

  4. Ryan TJ, Shim-Young N, Turk JL. Delayed pressure urticaria. Br J Dermatol. Aug 1968;80(8):485-90. [Medline].

  5. Kaplan AP, Horakova Z, Katz SI. Assessment of tissue fluid histamine levels in patients with urticaria. J Allergy Clin Immunol. Jun 1978;61(6):350-4. [Medline].

  6. Kerstan A, Rose C, Simon D, et al. Bullous delayed pressure urticaria: pathogenic role for eosinophilic granulocytes?. Br J Dermatol. Aug 2005;153(2):435-9. [Medline].

  7. Lawlor F, Bird C, Camp RD, et al. Increased interleukin 6, but reduced interleukin 1, in delayed pressure urticaria. Br J Dermatol. May 1993;128(5):500-3. [Medline].

  8. Di Lorenzo G, Pacor ML, Mansueto P, et al. Is there a role for antileukotrienes in urticaria?. Clin Exp Dermatol. Mar 2006;31(3):327-34.

  9. Kasperska-Zajac A, Brzoza Z, Rogala B. Increased concentration of platelet-derived chemokines in serum of patients with delayed pressure urticaria. Eur Cytokine Netw. Jun 2008;19(2):89-91. [Medline].

  10. Kasperska-Zajac A, Jasinska T. Analysis of plasma D-dimer concentration in patients with delayed pressure urticaria. J Eur Acad Dermatol Venereol. Feb 2011;25(2):232-4. [Medline].

  11. Champion RH. Urticaria: then and now. Br J Dermatol. Oct 1988;119(4):427-36. [Medline].

  12. Dover JS, Black AK, Ward AM, Greaves MW. Delayed pressure urticaria. Clinical features, laboratory investigations, and response to therapy of 44 patients. J Am Acad Dermatol. Jun 1988;18(6):1289-98. [Medline].

  13. Grob JJ, Gaudy-Marqueste C. Urticaria and quality of life. Clin Rev Allergy Immunol. Feb 2006;30(1):47-51. [Medline].

  14. Morioke S, Takahagi S, Iwamoto K, Shindo H, Mihara S, Kameyoshi Y. Pressure challenge test and histopathological inspections for 17 Japanese cases with clinically diagnosed delayed pressure urticaria. Arch Dermatol Res. Oct 2010;302(8):613-7. [Medline].

  15. Czecior E, Grzanka A, Kurak J, Misiolek M, Kasperska-Zajac A. Late Dysphagia and Dyspnea as Complications of Esophagogastroduodenoscopy in Delayed Pressure Urticaria: Case Report. Dysphagia. Jun 5 2011;[Medline].

  16. Barlow RJ, Ross EL, MacDonald D, Black AK, Greaves MW. Adhesion molecule expression and the inflammatory cell infiltrate in delayed pressure urticaria. Br J Dermatol. Sep 1994;131(3):341-7. [Medline].

  17. Barlow RJ, Ross EL, MacDonald DM, Kobza Black A, Greaves MW. Mast cells and T lymphocytes in chronic urticaria. Clin Exp Allergy. Apr 1995;25(4):317-22. [Medline].

  18. Magerl M, Borzova E, Giménez-Arnau A, Grattan CE, Lawlor F, Mathelier-Fusade P. The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations. Allergy. Dec 2009;64(12):1715-21. [Medline].

  19. Zuberbier T, Bindslev-Jensen C, Canonica W, et al. EAACI/GA2LEN/EDF guideline: management of urticaria. Allergy. Mar 2006;61(3):321-31. [Medline].

  20. Lawlor F, Black AK, Ward AM, Morris R, Greaves MW. Delayed pressure urticaria, objective evaluation of a variable disease using a dermographometer and assessment of treatment using colchicine. Br J Dermatol. Mar 1989;120(3):403-8. [Medline].

  21. Liu RH, Werth VP. What is new in the treatment of steroid-induced osteoporosis?. Semin Cutan Med Surg. Dec 2007;26(4):203-9. [Medline].

  22. Hartmann K, Hani N, Hinrichs R, Hunzelmann N, Scharffetter-Kochanek K. Successful sulfasalazine treatment of severe chronic idiopathic urticaria associated with pressure urticaria. Acta Derm Venereol. Jan-Feb 2001;81(1):71. [Medline].

  23. Kozel MM, Sabroe RA. Chronic urticaria: aetiology, management and current and future treatment options. Drugs. 2004;64(22):2515-36. [Medline].

  24. Kulthanan K, Thumpimukvatana N. Positive impact of chloroquine on delayed pressure urticaria. J Drugs Dermatol. Apr 2007;6(4):445-6. [Medline].

  25. Dawn G, Urcelay M, Ah-Weng A, O'Neill SM, Douglas WS. Effect of high-dose intravenous immunoglobulin in delayed pressure urticaria. Br J Dermatol. Oct 2003;149(4):836-40. [Medline].

  26. Metz M, Altrichter S, Ardelean E, Kessler B, Krause K, Magerl M, et al. Anti-immunoglobulin E treatment of patients with recalcitrant physical urticaria. Int Arch Allergy Immunol. 2011;154:177-80.

  27. Mitzel-Kaoukhov H, Staubach P, Müller-Brenne T. Effect of high-dose intravenous immunoglobulin treatment in therapy-resistant chronic spontaneous urticaria. Ann Allergy Asthma Immunol. Mar 2010;104(3):253-8. [Medline].

  28. Nettis E, Colanardi MC, Soccio AL, Ferrannini A, Vacca A. Desloratadine in combination with montelukast suppresses the dermographometer challenge test papule, and is effective in the treatment of delayed pressure urticaria: a randomized, double-blind, placebo-controlled study. Br J Dermatol. Dec 2006;155(6):1279-82. [Medline].

  29. Vena GA, Cassano N, D'Argento V, Milani M. Clobetasol propionate 0.05% in a novel foam formulation is safe and effective in the short-term treatment of patients with delayed pressure urticaria: a randomized, double-blind, placebo-controlled trial. Br J Dermatol. Feb 2006;154(2):353-6. [Medline].

 
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Table. Assessment Tool for Scoring* Severity of Disease[19]
ScoreWhealsPruritus
0NoneNone
1Mild (< 20 wheals/24 h)Mild
2Moderate (21-50 wheals/24 h)Moderate
3Intense (>50 wheals/24 h) or large confluent areasIntense
*Score = wheal score (0-3) + pruritus score (0-3); score range is 0-6.
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