A 48-year-old woman comes to the office due to a recurrent rash. Six months ago, a rash developed on her legs that she describes as "red patches with raised areas." The rash worsened that night with intense itching that disrupted her sleep. It spontaneously resolved over the next day. Since then, she has had repeated episodes of similar symptoms on her arms, legs, and back, each lasting 8-12 hours and occurring nearly every 2-3 weeks. She reports no trauma, insect bites, travel history, sick contacts, or changes in weight. Medical history is notable for hypertension treated with lisinopril. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min. Physical examination is within normal limits. The patient brings a photo of the rash, shown in the image below, from her most recent episode 2 days ago. Complete blood count, urinalysis, erythrocyte sedimentation rate, and liver function studies are within normal limits.
The patient currently has no rash but would like treatment recommendations for possible future episodes. Which of the following is the most appropriate treatment for this patient?

Question

A 48-year-old woman comes to the office due to a recurrent rash.  Six months ago, a rash developed on her legs that she describes as "red patches with raised areas."  The rash worsened that night with intense itching that disrupted her sleep.  It spontaneously resolved over the next day.  Since then, she has had repeated episodes of similar symptoms on her arms, legs, and back, each lasting 8-12 hours and occurring nearly every 2-3 weeks.  She reports no trauma, insect bites, travel history, sick contacts, or changes in weight.  Medical history is notable for hypertension treated with lisinopril.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.1 C (97 F), blood pressure is 138/77 mm Hg, and pulse is 78/min.  Physical examination is within normal limits.  The patient brings a photo of the rash, shown in the image below, from her most recent episode 2 days ago. Complete blood count, urinalysis, erythrocyte sedimentation rate, and liver function studies are within normal limits.
 The patient currently has no rash but would like treatment recommendations for possible future episodes.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be95_ee4b_8f63_8b6180749f9c_MD0005_00 Chronic spontaneous urticaria is usually treated with a stepwise approach. Although the pathogenesis of the condition is not fully elucidated, H1 antihistamines provide symptom control in many patients. Therefore, initial management includes a second-generation H₁ blocker (eg, loratadine, cetirizine) along with avoidance of any apparent aggravating factors (eg, heat, cold, stress). For persistent symptoms, the following may be added: First-generation H₁ blocker (eg, hydroxyzine) at bedtime (higher risk of sedation and anticholinergic side effects) (Choice B) Leukotriene receptor antagonist (eg, montelukast) (Choice C) H₂ blocker (eg, cimetidine) (conflicting data regarding efficacy), or Brief course of oral glucocorticoids (Choice D). Patients with refractory symptoms can be considered for immune-modulating therapies (eg, hydroxychloroquine, tacrolimus, omalizumab). (Choice E) Topical corticosteroids do not effectively treat chronic urticaria and can cause dermal atrophy when used for prolonged periods. Educational objective: The initial treatment for chronic spontaneous urticaria involves a second-generation H₁ blocker (eg, loratadine, cetirizine) and avoidance of aggravating factors (eg, heat, cold, stress). In patients with refractory symptoms, a first-generation H₁ blocker at bedtime, leukotriene receptor antagonist, H₂ blocker, or brief course of oral glucocorticoids can be tried. References: Chronic urticaria: an overview of treatment and recent patents. (http://www.ncbi.nlm.nih.gov/pubmed/30924425)

A 48-Year-Old Woman Comes to the Office Due to a Recurrent