eMedicine Specialties > Dermatology > Allergy & Immunology
Urticaria, Solar: Treatment & Medication
Updated: Nov 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
In rare systemic cases of solar urticaria, supportive medical measures to maintain blood pressure and adequate ventilation may be required if extensive cutaneous surfaces are simultaneously involved.
One case report describes 2 cases of idiopathic solar urticaria treated with intravenous immunoglobulin, with durable remissions of 13 months and 4 years, respectively. Treatment was with 2 g/kg over several 5-day courses approximately 1 month apart.5 Another case report also describes successful treatment of solar urticaria with intravenous immunoglobulin and suggests it should be discussed as an option if high-dose antihistamines provide unsatisfactory results.6
Medication
Treatment of solar urticaria can be frustrating. A combination of different modalities is often necessary, but the success of these methods is highly variable. Taking measures to avoid or minimize sun exposure is the most important step for patients with solar urticaria. Unfortunately, this often requires major adjustments in lifestyle, which might be impractical for some patients.
Antihistamines
Because solar urticaria involves IgE-mediated mast cell degranulation with consequent histamine release, the first line of treatment consists of long-acting, nonsedating H1-receptor blockers. Often, such agents achieve a protective factor of 10 or more. The extent to which this is useful depends on the severity of the disease itself. For example, someone who gets hives after just a few seconds of sun exposure is unlikely to benefit from antihistamine monotherapy. A patient requiring 10 minutes or more of exposure would show more benefit. Antihistamines seem to block wheal response and minimize pruritus, but they do not entirely eliminate an erythematous reaction. This tendency should be explained to the patient.
Cetirizine (Zyrtec)
Forms 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
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Because it is related to the highly sedating antihistamine hydroxyzine, some patients also experience drowsiness; caution in hepatic or renal dysfunction; doses >10 mg/d may cause drowsiness
Fexofenadine (Allegra)
Competes with histamine for H1 receptors in GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. Does not sedate.
Adult
180 mg/d PO
Pediatric
<6 months to 2 years: Not established; 15 mg (2.5 mL) PO bid recommended for chronic idiopathic urticaria
2-12 years: 30 mg PO bid
>12 years: Administer as in adults
Toxicity increases with coadministration of erythromycin and ketoconazole; concurrent administration with aluminum- or magnesium-containing antacids within 15 min decreases absorption
Documented hypersensitivity
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
Cardiac complications (dysrhythmias) may occur in high doses; no data available on use while breastfeeding
Loratadine (Claritin)
Selectively inhibits peripheral H1 receptors.
Adult
10 mg PO qd on empty stomach
Pediatric
<2 years: Not established
2-6 years: 5 mg/d PO
>6 years: Administer as in adults
Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels
Documented hypersensitivity
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 or renal impairment
Desloratadine (Clarinex)
Long-acting tricyclic histamine antagonist selective for H1 receptor. Relieves nasal congestion and systemic effects of seasonal allergy. A major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine.
Adult
5 mg PO qd
Pediatric
<6 months: Not established
6-12 months: 2 mL (1 mg) syr PO qd
1-6 years: 2.5 mL (1.25 mg) syr PO qd
6-12 years: 5 mL (2.5 mg) syr or 2.5 mg PO qd
>12 years: Administer as in adults
Limited data exist; erythromycin and ketoconazole increase desloratadine and 3-hydroxydesloratadine plasma concentrations, but no increase in clinically relevant adverse effects, including QTc, has been observed
Documented hypersensitivity
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; adjust dose in renal impairment
Antimalarials
Used to treat certain photosensitive eruptions, including solar urticaria. Efficacy is unpredictable.
Hydroxychloroquine (Plaquenil)
Inhibits chemotaxis of eosinophils and locomotion of neutrophils. Impairs complement-dependent antigen-antibody reactions.
Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.
Adult
200 mg PO bid
Pediatric
10 mg base/kg initially, followed by 5 mg/kg at 6, 24, and 48 h
Serum levels increase with cimetidine; magnesium trisilicate may decrease absorption
Documented hypersensitivity; psoriasis; retinal and visual field changes attributable to 4-aminoquinolones
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
Caution in hepatic disease, G-6-PD deficiency, psoriasis, and porphyria; not recommended for long-term use in children; perform periodic (q6mo) ophthalmologic examinations (include visual acuity, slit-lamp, funduscopic, and visual field tests); periodically test for muscle weakness; periodic CBC counts should be checked; hemolysis, aplastic anemia, agranulocytosis, and leukopenia can occur
Histamine H2-receptor antagonists
Usually given in addition to H1 blockers.
Ranitidine (Zantac)
H2 antagonist that, when combined with H1 type, may be useful in treating allergic reactions that do not respond to H1 antagonists alone.
Adult
150 mg PO bid
Pediatric
<1 month: Not established
>1 month to 12 years: 2-4 mg/kg PO qd; not to exceed 150 mg/d
>12 years: 1.25-2.5 mg/kg/dose PO q12h; not to exceed 300 mg/d; alternatively, 0.75-1.5 mg/kg/dose IV/IM q6-8h; not to exceed 400 mg/d
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin; may decrease effectiveness of bisacodyl if given within 1 h of H2 blocker; drugs that raise gastric pH, such as H2 blockers, reduce cefpodoxime absorption
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment; elevation of transaminase enzymes has occurred with prolonged IV therapy
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| Differential Diagnoses & Workup: Urticaria, Solar |
 Treatment & Medication: Urticaria, Solar |
| Follow-up: Urticaria, Solar |
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References
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Fukunaga A, Horikawa T, Yamamoto A, Yamada Y, Nishigori C. The inhibition spectrum of solar urticaria suppresses the wheal-flare response following intradermal injection with photo-activated autologous serum but not with compound 48/80. Photodermatol Photoimmunol Photomed. Jun 2006;22(3):129-32. [Medline].
Harris A, Burge SM, George SA. Solar urticaria in an infant. Br J Dermatol. Jan 1997;136(1):105-7. [Medline].
Lecha M, Puy H, Deybach JC. Erythropoietic protoporphyria. Orphanet J Rare Dis. Sep 10 2009;4:19. [Medline].
Hughes R, Cusack C, Murphy GM, Kirby B. Solar urticaria successfully treated with intravenous immunoglobulin. Clin Exp Dermatol. Jun 17 2009;[Medline].
Maksimovic L, Fremont G, Jeanmougin M, Dubertret L, Viguier M. Solar urticaria successfully treated with intravenous immunoglobulins. Dermatology. 2009;218(3):252-4. [Medline].
Dawe RS, Ferguson J. Prolonged benefit following ultraviolet A phototherapy for solar urticaria. Br J Dermatol. Jul 1997;137(1):144-8. [Medline].
Collins P, Ahamat R, Green C, Ferguson J. Plasma exchange therapy for solar urticaria. Br J Dermatol. Jun 1996;134(6):1093-7. [Medline].
Fotiades J, Soter NA, Lim HW. Results of evaluation of 203 patients for photosensitivity in a 7.3-year period. J Am Acad Dermatol. Oct 1995;33(4):597-602. [Medline].
Khoo SW, Tay YK, Tham SN. Photodermatoses in a Singapore skin referral centre. Clin Exp Dermatol. Jul 1996;21(4):263-8. [Medline].
Roelandts R. Diagnosis and treatment of solar urticaria. Dermatol Ther. 2003;16(1):52-6. [Medline].
Roelandts R, Ryckaert S. Solar urticaria: the annoying photodermatosis. Int J Dermatol. Jun 1999;38(6):411-8. [Medline].
Ryckaert S, Roelandts R. Solar urticaria. A report of 25 cases and difficulties in phototesting. Arch Dermatol. Jan 1998;134(1):71-4. [Medline].
Shimauchi T, Kabashima K, Tokura Y. Solar urticaria as a manifestation of Churg-Strauss syndrome. Clin Exp Dermatol. Mar 2007;32(2):209-10. [Medline].
Further Reading
Keywords
solar urticaria, sun hives, allergy, allergic reaction, anaphylaxis, anaphylactoid reaction, angioedema, photodermatosis, pruritus, solar irradiation, minimum urticarial dose, MUD, polymorphous light eruption, PMLE, erythropoietic protoporphyria, lupus erythematosus, photocontact dermatitis, miliaria rubra, psoralen–UV-A, PUVA, phototherapy, UV-A, broadband UV-B, narrowband UV-B, photochemotherapy, methoxsalen
