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 is concerned about her long-term prognosis. Which of the following is the most appropriate advice 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 is concerned about her long-term prognosis.  Which of the following is the most appropriate advice for this patient?

Quizplus · Accepted Answer

Explanation: The symptoms of chronic urticaria are usually controllable without difficulty, with >50% of patients responding to standard therapy (Choice B). It is usually a self-limited condition that resolves spontaneously within 2-5 years, with remission rates of nearly 30%-50% at 1 year and up to 70% by 5 years. Patients with more severe episodes, angioedema, or autoimmune thyroid disease have a longer disease duration. The urticaria in those with symptoms lasting >5 years also generally improves, with up to 50% of patients achieving remission within the next 5 years (Choice C). (Choice A) Chronic urticaria without angioedema, as seen in this patient, is usually not life threatening and does not require an epinephrine injector. In contrast, acute urticaria with angioedema can sometimes be associated with life-threatening allergic reactions, requiring the patient to carry epinephrine. (Choice E) Dietary changes usually do not improve chronic urticaria because IgE-mediated food reactions are not typically associated with it. However, such reactions may cause acute urticaria and can improve with dietary modifications after the causative allergen is identified. Educational objective: Chronic spontaneous urticaria is a self-limited condition that usually responds to standard therapy and resolves within 2-5 years in most cases. 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