Cold urticaria, clinical case 4, Centre of Evidence of Dermatology

Chronic spontaneous urticaria and diet

Back to decision-making tree Print last updated on 25/02/2024

Presentation

Mr R., 45 years old, has had CSU for 3 months, triggered, in his opinion, by a meal at an Asian fast-food restaurant. His attending physician prescribed biological tests (CBC, sed rate, CRP, TSH, anti-thyroid antibodies and stool examination for parasites), the results of which were normal. Mr R. is convinced that his urticaria is caused by food, but he is unable to identify the foods at the root of his problem.

Previous treatments

He has taken: desloratadine, then levocetirizine at conventional doses (MA dose, 1 tablet/day), and for the past week mizolastine 1 tablet/day and ranitidine 1 tablet/day, without any improvement.

Other elements

He has a history of atopy, depression following the loss of his job and chronic lower-back pain. His usual treatment includes: escitalopram (1 tablet/day) and ibuprofen regularly for back pain (self-medication).

What do you suggest?

See proposition

Proposition

Information

Explain that CSU is a benign skin condition with a non-allergic causal mechanism that can stop spontaneously after a few weeks, months or years.
Explain that diet is not an issue in CSU. However, you may suggest that the patient keep a diary of food intake and CSU flare-ups for a period of 15 to 30 days to reassure the patient that his diet is not responsible. It is not recommended to propose a systematic food avoidance diet.
Explain that non-steroidal anti-inflammatory drugs (including ibuprofen) may promote urticaria flare-ups through a pharmacological mechanism on leukotrienes (non-allergic reaction).

Assessment

The treatment depends on the patient’s level of discomfort. It is necessary to assess the impact of CSU on his quality of life (using the /home/clients/2d968a8758d292fa1ac968882da338c1/vhost/sfdermato.org/reco/dev/APP/view/content/uaf/cas/vignette-04.php on line 51
">DLQI or CU-QoL scores) and the severity of CSU (UCT and UAS7 scores).

Treatment

Mizolastine should be discontinued due to the risk of QT prolongation with escitalopram.
Ranitidine should be discontinued because it is ineffective in this patient, and there is no evidence in the literature of the efficacy of anti-H2 antihistamines in CSU.
Prescribe an anti-H1 antihistamine that does not prolong the QT (e.g. cetirizine, levocetirizine) by suggesting 2 doses/day for 1 week, then 3 doses for 1 week, then 4 doses (2 in the morning, 2 in the evening) in case of ineffectiveness. ^*Most experts recommend proceeding directly to 4 doses of anti-H1 antihistamines and then decreasing to 3 and then to 2 after achieving remission.
Propose a follow-up at 1 or 2 months to discuss further treatment in case of failure and depending on the severity of CSU and its impact on the patient’s quality of life.

References

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Centre of Evidence of Dermatology Best practice guidelines

Guidelines cold urticaria Updated on january 2024

Responsibility

Chronic spontaneous urticaria and diet

Presentation

Previous treatments

Other elements

What do you suggest?

Proposition

Information

Assessment

Treatment

References