How to manage urticaria (hives)

Urticaria, or hives, is a dermatological condition. Its main symptoms are raised and itchy welts that appear on the skin. In most cases, urticaria does not seriously affect physical health. However, it can significantly impact a patient's quality of life due to discomfort and aesthetic concerns.

For primary care doctors looking to expand their expertise into general dermatology, understanding the fundamentals of managing urticaria is essential. This article aims to provide guidelines for the diagnosis and management of urticaria in a primary care setting.

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in General Dermatology.

How to recognise urticaria

Urticaria presents as transient, erythematous wheals with well-defined borders. It is usually accompanied by pruritus.

The lesions can vary in size and shape and may appear suddenly on any part of the body. They result from the release of histamine and other inflammatory mediators and can be triggered by allergic or non-allergic factors.

Identifying potential triggers and differentiating between acute and chronic urticaria is crucial for effective management.

How to diagnose urticaria 

The first step towards diagnosing urticaria is obtaining a detailed patient history. This includes the onset, duration, and frequency of symptoms. Also, it is vital to inquire about potential triggers such as:

• Medications
• Foods
• Infections
• Environmental factors

A thorough physical skin examination to assess the distribution and characteristics of the lesions is also necessary. It is important not to miss the potential signs of angioedema, which may accompany urticaria.

Last but not least, comprehensive allergy testing is needed if allergic triggers are suspected.

How to treat urticaria

The treatment plan depends on the type of urticaria, which can be acute or chronic.

Acute urticaria

The treatment of acute urticaria typically includes:

• Identification and elimination of triggers: Primary care doctors can, in some cases, identify certain triggers and advise the patient to avoid them.
• Antihistamines: Prescribing second-generation non-sedating antihistamines such as cetirizine, loratadine, or fexofenadine as first-line treatment. These medications effectively relieve itching and reduce the frequency and severity of hives.
• Short-course corticosteroids: In severe cases or when antihistamines alone are insufficient, a short course of oral corticosteroids may be prescribed to rapidly suppress inflammation.

Chronic urticaria

For chronic urticaria, the best treatment options are:

• Antihistamines: Similar to acute urticaria, second-generation antihistamines are the mainstay of treatment. However, higher doses or combination therapy may be necessary for adequate symptom control.
• Second-line therapies: For refractory cases, GPs may consider alternative therapies such as:
  • Leukotriene receptor antagonists (montelukast),
  • H2-receptor antagonists (ranitidine), or
  • Omalizumab (anti-IgE monoclonal antibody)

These options can be effective in reducing symptoms and improving quality of life.

• Lifestyle modifications: Doctors should encourage patients to adopt a healthy lifestyle, including stress reduction techniques, regular exercise, and avoidance of known triggers.

Urticaria follow-up and referral

After the treatment, it is pivotal to schedule follow-up appointments to assess treatment response and adjust therapy as needed.

In complex cases, GPs can consider referral to a dermatologist. Particularly if symptoms persist despite optimal therapy, or if additional diagnostic evaluations are needed.

Educating the patients about their condition is invaluable. This empowers them with knowledge about their condition, including potential triggers and available treatment options.

The bottom line

It is possible to successfully manage urticaria/hives in a primary care setting. However, that requires adequate training in general dermatology and a systematic approach that integrates diagnostic evaluation, patient education, and evidence-based treatment strategies.

By familiarising themselves with the fundamentals of urticaria management, and through collaboration with dermatologists and allergists, primary care doctors can effectively address this common dermatological condition and improve patient outcomes.

– Dr Rosmy De Barros

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in General Dermatology.

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References:

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