Chronic spontaneous urticaria clinical case 3, Centre de Preuves en Dermatologie

chronic spontaneous urticaria Dec 19

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Primary care management of chronic spontaneous urticaria

Presentation

Mrs U., 32 years old, consults for migratory and transient red plaques, occurring over the past 3 days. The rash is itchy and prevents her from sleeping. You make the diagnosis of acute urticaria and propose treatment with 1 tablet of desloratadine 5 mg for 15 days. You cannot identify any triggers for this acute urticaria. A complete clinical examination is normal apart from the urticarial plaques.
She returns to see you 2 months later, consulting for the persistence of the urticarial rash (photograph). No contributing factors are found in the patient interview. She has doubled the dose of desloratadine in the last 3 weeks: the lesions are more discreet and less pruritic, but still present and remain uncomfortable.

Other elements

Mrs U. has no particular antecedents, apart from a cruciate ligament rupture (skiing injury). She is not taking any treatment other than anti-H1 antihistamines, is not using contraception and is planning to become pregnant.

What do you suggest?

See proposition

Proposition

Information

This is a case of chronic spontaneous urticaria (CSU), a mild, non-contagious skin condition that can stop spontaneously after a few weeks, months or years.
Corticosteroids are not recommended in CSU.
Regarding any possible joint pain, NSAIDs may increase CSU flare-ups.

Treatment

Discuss a biological exploration. ^*Concerning a possible biological exploration, some experts do not propose any tests; others propose: CBC, VS, C-reactive protein (CRP) and sometimes the determination of anti-thyroid antibodies.
Increase the dose of anti-H1 antihistamines to 3 doses/day for 1 week, then 4 doses/day (2 in the morning, 2 in the evening) in case of inefficacy. ^*Most experts recommend proceeding directly to 4 doses of anti-H1 antihistamines, then decreasing to 3 doses, and then to 2 after achieving remission.
Prefer desloratadine, levocetirizine and cetirizine: there is extensive data on pregnancy and multiple doses; the Centre de Référence sur les Agents Tératogènes (CRAT, www.lecrat.fr) can be consulted, or a regional pharmacovigilance centre.
Schedule a new consultation in 4 to 8 weeks if improvement is not significant, or in case of recurrence. The impact on quality of life should guide further management. In case of failure of anti-H1 treatment with quadruple the MA dose, arrange for consultation with a specialist.

References

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Work

10 cité Malesherbes

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Île-de-France

FRANCE

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chronic spontaneous urticaria Dec 19