A 55-year-old woman comes to the physician with a 6-month history of a diffuse rash. The patient has episodes of localized itching on her arms followed by a rash that worsens over a few hours before spontaneously resolving. The rash has also occurred on her arms, legs, and back. The most recent episode occurred 2 days ago, and the patient has brought a photograph of the rash, shown below. She has no trauma, insect bites, travel history, or sick contacts. The patient has a history of hypertension, diabetes, and osteoarthritis of her knees. Her medications include metformin, lisinopril, and occasional ibuprofen. She does not use tobacco, alcohol, or illicit drugs.
The patient's temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min. Her physical examination is within normal limits.

Which of the following is the next best step in management of this patient?

Question

A 55-year-old woman comes to the physician with a 6-month history of a diffuse rash.  The patient has episodes of localized itching on her arms followed by a rash that worsens over a few hours before spontaneously resolving.  The rash has also occurred on her arms, legs, and back.  The most recent episode occurred 2 days ago, and the patient has brought a photograph of the rash, shown below.  She has no trauma, insect bites, travel history, or sick contacts.  The patient has a history of hypertension, diabetes, and osteoarthritis of her knees.  Her medications include metformin, lisinopril, and occasional ibuprofen.  She does not use tobacco, alcohol, or illicit drugs.
The patient's temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min.  Her physical examination is within normal limits.

Which of the following is the next best step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9789_7b91_853d_39437d096c82_MD0002_00 This patient's clinical features are consistent with chronic urticaria, defined as episodic symptoms lasting >6 weeks. Urticaria is due to mast cell activation in the superficial dermis, with release of multiple mediators (eg, histamine) that cause pruritus and localized swelling in the upper layers of the skin. It can also be associated with angioedema due to mast cell activation in the deeper dermal and subcutaneous tissues. Chronic urticaria can be due to physical stimuli (eg, cold temperature, skin pressure), serum sickness, or systemic disorders (eg, autoimmune disease, vasculitis, malignancy). However, for many patients, the cause is not known (idiopathic urticaria). Chronic urticaria is usually treated in a stepwise approach, initially with a second-generation (nonsedating) antihistamine (eg, loratadine). If needed, the dose may be increased to 2-4 times the standard dose. Second-line therapies in patients who do not respond include a first-generation antihistamine, a leukotriene receptor antagonist, and an H₂ blocker. Patients with persistent symptoms may require subspecialist referral for immunosuppressive therapies (eg, hydroxychloroquine, tacrolimus, omalizumab). (Choice A) First-generation antihistamines, such as diphenhydramine or hydroxyzine, are associated with significant sedation. They can be added at bedtime in patients who do not respond to nonsedating antihistamines alone. (Choices C and E) Leukotriene receptor antagonists and H2 blockers are useful add-on therapies in patients who do not respond to initial therapy. They are only marginally effective in monotherapy for initial treatment. (Choice D) Oral glucocorticoids may be used in brief courses in patients who fail initial therapy. But they are associated with significant adverse effects when used for extended periods. Educational objective: Initial treatment of chronic urticaria includes second-generation antihistamines (eg, loratadine). Treatment for refractory patients includes first-generation antihistamines, leukotriene receptor antagonists, H₂ blockers, or a brief course of oral steroids. __________ References: EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. (http://www.ncbi.nlm.nih.gov/pubmed/19772513)

A 55-Year-Old Woman Comes to the Physician with a 6-Month