Sauer note

Dermographism is commonly overlooked as a cause of the patient's "welts" or vague itching.

Inhalants. Nasal sprays, insect sprays, dust, feathers, pollens, and animal danders are some offenders.

Infections. A focus of infection is always considered, sooner or later, in chronic cases of hives, and in unusual instances it is causative. The sinuses, the teeth, the tonsils, the gallbladder, and the genitourinary tract should be checked.

Internal disease. Urticaria has been seen with liver disease, intestinal parasites, cancer, rheumatic fever, and others.

"Nerves." After all other causes of chronic urticaria have been ruled out, there remain a substantial number of cases that appear to be related to nervous stress, worry, or fatigue. These cases benefit most from the establishment of good rapport between the patient and the physician.

Contact Urticaria Syndrome. This uncommon response can be incited from the local contact on the skin of drugs and chemicals, foods, insects, animal dander, and plants.

Cholinergic Urticaria. Clinically, small papular welts are seen that are caused by heat (hot bath), stress, or strenuous exercise. Differential Diagnosis

Hebra's erythema multiforme: Systemic fever, malaise, and mouth lesions are noted in children and young adults (see the next section of this chapter).

Dermographism: A common finding in young adults, especially those who present complaining of welts on their skin or vague itching of the skin with no residual lesions. To make the diagnosis, stroke the skin firmly to see if an urticarial response develops. The course can be chronic, but hydroxyzine, 10 mg b.i.d. or t.i.d., is quite helpful. (Warn the patient about the possibility of drowsiness.)

Urticarial vasculitis: Lesions may last more than 24 hours, be painful, leave a bruise, and be associated with hypocomplementemia. Treatment

For a case of acute hives due to penicillin injection 1 week previously for a "cold":

1. Colloidal bath

Sig: Add 1 cup of starch or oatmeal (Aveeno) to 6 to 8 inches of lukewarm water in the tub. Bathe for 15 minutes once or twice a day.

2. Sarna Lotion or PrameGel OTC Sig: Apply p.r.n. locally for itching.

3. Hydroxyzine (Atarax), 10 mg #30 Sig: Take 1 tablet t.i.d., a.c. (drowsiness warning).

4. Diphenhydramine (Benadryl), 50 mg Comment: Available over the counter

5. Betamethasone sodium phosphate (Cele-stone), 3 mg/mL Sig: Inject 1 to 1.5 mL subcutaneously.

For a more severe case of acute hives:

1. Benadryl injection

Sig: Inject 2 mL (20 mg) subcutaneously, or

2. Epinephrine hydrochloride

Sig: Inject 0.3 to 0.5 mL of 1:1000 solution subcutaneously, or

3. Prednisone tablets, 10 mg #30 Sig: Take 1 tablet q.i.d. for 3 days, then 1 tablet in morning as necessary.

For treatment of patient with chronic hives of 6 months' duration when cause is undetermined after careful history and examination:

1. Hydroxyzine (Atarax), 10 to 25 mg #60 Sig: Take 1 tablet t.i.d. depending on drowsiness and effectiveness. Continue for weeks or months.

Clemastine (Tavist) 1.34 or 2.68 mg #30

Cyproheptadine (Periactin) 4 mg #60

2. Loratadine (Claritin) 10 mg #30 Sig: Take 1 tablet once a day

Cetirizine (Zyrtec) 5 mg or 10 mg #30

Sig: Take 1 tablet once a day

Fexofenadine (Allegra), 60 mg #30

Sig: Take 1 tablet once a day

3. Cimetidine (Tagamet), 300 mg #60 Sig: Take 1 tablet t.i.d.

Comment: This H2 blocker is of benefit in some cases, and can be added to HI blockers.

4. Suggest avoidance of chocolate, nuts, cheese and other milk products, seafood, strawberries, pork, excess spicy foods, and excess of coffee or tea.

5. Keep a diet diary of everything ingested (including all foods, all medicines, even over-the-counter, candy, menthol cigarettes, chewing gum, chewing tobacco, mouthwash, breath fresheners, etc.) and then see what items were used 12 to 24 hours before the episode of hives occurred.

6. A mild sedative or tranquilizer such as meprobamate, 400 mg t.i.d., or chlordiazepoxide (Librium), 5 mg t.i.d., may help.

7. Doxepin (Sinequan) 10 mg #60 Sig: 1 tablet t.i.d.

Comment: This is a tricyclic antidepressant with potent antihistaminic properties. It can cause drowsiness, dry mouth, and other side effects of this classification of drugs.

8. Immunosuppressive drugs such as Predni-sone are unfortunately necessary in severe cases.

9. Ketotifen fumarate is a mast cell stabilizer not yet approved in the United States but found in other countries with benefit in severe cases.

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