Approach Considerations

Traditional treatment options for cholinergic urticaria are antihistamines, leukotriene inhibitors, and immunosuppressives.^{[5, 28]}However, cholinergic urticaria in some patients may be refractory.

Sometimes, an attack of cholinergic urticaria can be aborted by rapid cooling. Ultraviolet (UV) light has been beneficial in some patients with the condition, but one must be circumspect about contraindications to UV light.

Rapid desensitization with autologous sweat has been reported in patients resistant to conventional therapy who have sweat hypersensitivity.^[29]

In evaluating any response to therapy, one must always consider that cholinergic urticaria can clear spontaneously.

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.

Deterrence/prevention

Patients with cholinergic urticaria should avoid the precipitating factors. These factors, in some persons, include exercise and any activity that causes sweating, such as elevated environmental temperature, hot food, sauna baths, immersion in hot water, gustatory stimuli, emotional stress, and hemodialysis.^[30]

Long-term monitoring

A quality-of-life questionnaire has been developed for cholinergic urticaria.^[31]

Pharmacologic Therapy

Antihistamines, including cetirizine, are helpful for cholinergic urticaria. Second-generation antihistamines are generally regarded as first-line therapy.^[32]The response to cetirizine is important because some of the antihistaminic effect has been attributed to antimuscarinic activity. Some data suggest that a combination of H1 and H2 blockers is more effective than combining different H1 blockers.^[33]The antimuscarinic cholinergic methanthelinium bromide has also been suggested as a therapeutic option.^[34]

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 is another agent that can be beneficial for patients with cholinergic urticaria, ostensibly because it elevates antichymotrypsin levels.

Oral cyclosporine is another option,^[35]as is dupilumab, although more experience with both may be desirable.^[36]

Beta-blockers, such as propranolol, have also been reported to be useful in treating the disease.^[37]

Topically applied benzoyl scopolamine and oral scopolamine butylbromide, where available, may be helpful in blocking the appearance of cholinergic urticaria lesions after challenge.^[38]

Medication

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