Chronic spontaneous urticaria clinical case 3, Centre of Evidence of Dermatology

Primary care management of chronic spontaneous urticaria

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.

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.

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.

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.

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