Controlling rashes that appear out of nowhere and don’t go away (chronic spontaneous urticaria)

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Chronic spontaneous urticaria (CSU), which is a rash (hives) that lasts six weeks or longer (chronic) and has an unknown cause (spontaneous), can significantly impact your life. The itching of hives can make you feel self-conscious. It could make it difficult to sleep and lead to fatigue, which in turn can lead to irritability and depression, which can lead to personal and professional problems. Severe swelling of the lips, eyelids, hands, feet, and other areas of the body may occur. And if you scratch it, the skin could break, which could lead to an infection. So what can you do if you have a CSU?

Find the right healthcare provider

If you develop hives, primary care doctors are usually your first choice. However, if the treatment does not work, you should ask for a referral to a specialist, such as an allergist or dermatologist. Allergists can perform tests to rule out allergies or autoimmune diseases. They also have the most up-to-date information on the different types of antihistamines and other advanced medications used to treat allergies. Dermatologists, on the other hand, have experience prescribing immunosuppressive treatments, medications that reduce the immune system’s response, for many types of skin conditions.

Prepare for consultations on the treatment of chronic spontaneous urticaria

Regardless of which specialist you consult, it is important that you prepare for your consultations so that you don’t leave realizing there were things you didn’t talk about.

Monitor your symptoms: Use apps or paper to record data and symptoms and monitor when hives come and go, how long they last, and what triggers may have caused them. Clearly describe symptoms and whether any treatment seemed to work.

Monitor your quality of life: It is important to monitor your hives and their effects on you. You can tell your healthcare provider (HCP) how the itching is keeping you awake, causing you to miss work, or causing anxiety, for example.

Always bring a list of medications with you to your appointments: You can bring your medication list (including supplements, vitamins, and other over-the-counter skin creams) or ask a pharmacist to print an updated list of your medications.

Bring a list of questions: Before your first visit and between visits, keep a running list of questions so you can remember them when you see them.

Treatment of chronic spontaneous urticaria

Because CSU is not the result of an allergy or a specific external trigger, it does not always respond to the same types of treatments as regular skin rashes. CSU is thought to be caused by an overactive immune system, meaning treatments should target things other than the itching of the rash. There are different types of medications that healthcare providers can use to treat CSU. You may need to try several medications to find what works for you. One of the questions you should ask your doctor when trying a new medication is: “How long does it take for the medication to work?” This way you know how long you have to wait and don’t get discouraged if it doesn’t work right away. You will also learn if the medication is not working for you and if you should try another option.

Treatment options for urticaria

Antihistamines

Antihistamines are usually the first treatment tried for CSU. You can buy antihistamines without a prescription, but some require a prescription. Antihistamines commonly used in CSU include:

• Cetirizina (Zyrtec)
• Desloratadina (Clarinex)
• Fexofenadine (Allegra)
• Levocetirizine (Xyzal)
• Loratadine (Claritin)

When these medications work, they often take effect within days or weeks, sometimes after just a single dose.

Steroids

Corticosteroids such as prednisone or prednisolone, which are oral pills, can be helpful in controlling inflammation, which can reduce severe flare-ups. However, these are short-term solutions and do not address the problem that caused the hives in the first place. These medications are not used for long-term treatment because of the risk of serious side effects. Steroid creams or other preparations applied to the skin do not work for CSU.

Medicines for asthma, allergies and eczema

Research has found that some medications commonly used to treat asthma, allergies, or eczema may be helpful in controlling CSU symptoms in people for whom taking other medications is not effective. Montelukast (Singulair) is one. It belongs to the therapeutic class of leukotriene receptor antagonists. Your doctor may recommend antihistamines. There isn’t much research on how long it takes to take effect, but some case studies have shown that some patients feel the effects within weeks.

Dupilumab (Dupixent) and malizumab (Xolair and Omlyclo) are biopharmaceuticals approved for the treatment of CSU and are administered via monthly injections. Some people taking these medications notice relief from their symptoms within weeks, but others may take longer.

Immunosuppressants

Immunosuppressants are medicines used to treat diseases in which the body attacks itself. They are used for many diseases, such as multiple sclerosis, inflammatory bowel disease and rheumatoid arthritis. Some immunosuppressants may be useful in treating CSU, including:

• Acalabrutinib (Calquence)
• Azathioprine (Imuran)
• Ciclosporin (Gengraf, Neoral and Sandimmune)
• Hydroxychloroquine (Plaquenil)
• Methotrexate
• Mizorbina
• Mycophenolate mofetil
• Tacrolimus

Some patients notice improvements after weeks, others after months.

This educational resource was created with support from Regeneron and Sanofi.

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