Pressure Urticaria Treatment & Management

Updated: Jan 25, 2019
  • Author: Sarah Beggs, MD; Chief Editor: Dirk M Elston, MD  more...
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Approach Considerations

Patients should avoid triggers of urticaria and 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.

Second-generation antihistamines are considered first-line treatment for delayed pressure urticaria (DPU); however, DPU is relatively refractory to antihistamines. [28, 29] Omalizumab has shown promise for chronic inducible urticaria (CIndU) in patients with disease refractory to antihistamines, with few adverse effects. [30, 31, 32, 33, 34, 35] Systemic corticosteroid treatment leads to improvement of DPU; however, its use is limited owing to its adverse effect profile. Second- and third-line agents used have included colchicine, dapsone, sulfasalazine, montelukast, chloroquine, cyclosporine, intravenous immunoglobulin (IVIg), and anakinra. [28, 36, 37, 38, 39, 40, 41, 42, 43, 44]

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


Pharmacologic Therapy

Antihistamines can reduce the severity of swelling and frequency of urticaria and are helpful in controlling associated chronic idiopathic urticaria (CIU). There are few adverse effects of antihistamines, mainly sedation, which is less potent in the second-generation antihistamines. Some authors have suggested up to 4 times the recommended dose of nonsedating antihistamines to achieve control. However, delayed pressure urticaria (DPU) has notoriously been known to be refractory to antihistamines and antihistamines may not control the symptoms completely. [28, 29]

Omalizumab, a recombinant DNA monoclonal antibody that binds to IgE, is showing promising results in CIU, with few adverse effects, owing to its ability to decrease mast cell degranulation. It is approved by the US Food and Drug Administration for CIU, but not necessarily for chronic inducible urticaria (CIndU). Studies published in early 2019 express hope there will soon be approval for CIndU. [34] Three phase 3 clinical trials, ASTERIA I, ASTERIA II, and GLACIA, involving over 900 patients with chronic spontaneous urticaria showed the benefits of omalizumab. [45] A phase 3, multicenter study has shown that omalizumab decreased itchiness and hives and increased quality of life (QOL) in patients with CIU or chronic spontaneous urticaria, whose disease had been refractory to antihistamine therapy. [30] Patients, including those with DPU, who initially had a positive response to omalizumab, and then relapsed after stopping treatment, achieved remission after restarting omalizumab. [31] Multiple case reports have reported the benefit of omalizumab treatment in patients with DPU. [30, 31, 32, 33, 35]

Steroids are best restricted for recalcitrant and severe DPU. [21] 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. [46] 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. [47] Methotrexate has been used successfully in steroid reduction in a few patients with steroid-dependent DPU. [45]

NSAIDs produce variable responses. As treatment, they may be suboptimal because they, along with aspirin, may worsen urticaria and angioedema. 

Other therapeutic agents that have been tried include colchicine, dapsone, sulfasalazine, and montelukast. [28, 36, 44, 48, 49, 50] Colchicine has been largely ineffective as a therapy. [50] 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, 44] ; other forms of chronic urticaria have not demonstrated similar responses to this treatment. Case reports have demonstrated some success with chloroquine, cyclosporine, IVIg, tricyclic antidepressants, selective serotonin reuptake inhibitors, and anakinra. [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]