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Urticaria (Hives)

Urticaria (Hives) Urticaria refers to a group of skin disorders characterised by weals (also called hives) or angiodema, or both weals and angiodema forming on the skin. There are several different types of urticaria. Weals (also spelt wheal) may last from a few minutes to several hours and are pale or skin-coloured superficial swellings, usually surrounded by erythema (redness). Weals are generally itchy, 1–2cm in width, and may merge together to form a map-like pattern or one giant patch. The term urticaria is derived from the Latin word for stinging nettle, Urtica dioica. Occasionally, the surface weals may be accompanied by angioedema – which is a swelling beneath the skin that usually occurs around the facial area (ie, eyes and lips) but may also be present on the hands, feet, and throat. Angiodema may progress to anaphylaxis; symptoms include breathing and swallowing difficulty and shock (see Allergies). Urgent medical advice must be sought. Angioedema may also occur without weals. Urticaria can occur anywhere on the body but is mainly found on the trunk, arms and legs. Sometimes the rash can change shape and disappear from one place, only to reappear a few hours later somewhere else. The underlying chemical responsible for urticaria is histamine. Most cases of urticaria resolve within a few days although, occasionally, a person will have hives for many months or years. Acute urticaria Acute urticaria refers to a rash that lasts for less than six weeks. The rash may be triggered by an allergy or another non-allergic cause. Mast cells and white blood cells in the skin release histamine, which causes small blood vessels to leak fluid which pools to form weals. In acute urticaria due to an allergic cause, the substance responsible is usually ingested, inoculated, or inhaled, though in some people skin contact with the allergen may be enough to set off the urticaria (eg, latex). The most common allergic causes of urticaria are: • bee or wasp stings • foods – particularly nuts, fish or shellfish, eggs, tomatoes, eggs, berries, milk, strawberries and kiwifruit • latex • medicines – almost any type of medicine, either prescription or over the counter, although antibiotics are the most commonly implicated. Most cases of urticaria are NOT due to allergy, and can occur without previous exposure. Non-allergic causes of acute urticaria include: • contact with irritating plants (eg, thistles, stinging nettle) or stinging jellyfish • infections – such as viral upper respiratory tract infections (eg, colds, sinusitis), Candida infections, dental abscesses, Helicobacter pylori, viral hepatitis • non-allergic food reactions – common examples include salicylates in fruits, azo-dye food-colouring agents, benzoate preservatives, and histamine due to bacterial decomposition in fish (eg, scombroid fish poisoning) • non-allergic release of mast-cell granules, which can occur with opiates (eg, morphine, codeine) and radio-contrast agents • serum sickness – as a result of a blood transfusion, viral infection or medicines. TREATMENT OPTIONS Category Examples Comments Oral antihistamines Topical anti-itch products Natural / herbal products / supplements Non-sedating [PHARMACY ONLY MEDICINE] eg, cetirizine (Razene, Allerid-C, Histaclear, Zetop, Zyrtec tablets & liquid), desloratadine (Aerius Tablets), fexofenadine (Arrowcare Fexofast*, Hayfexo, Fexoclear, Telfast 180*, Telfast Oral Liquid For Kids, Xergic), levocetirizine (Levrix), loratadine (Loraclear, Lorafix) Sedating [PHARMACIST ONLY MEDICINE] eg, dexchlorpheniramine (Polaramine), promethazine (Phenergan, Allersoothe) [PHARMACY ONLY MEDICINE] eg, Anthisan Cream Vitamin C Aloe vera gel These help to control total body itch and wheals. Try and eliminate the underlying cause (eg, food, medication). Oral antihistamines are more convenient than topical antihistamines when itch affects the whole body area. Generally non-sedating medicines do not cause drowsiness; however, some people may be more sensitive than others. Warn about the risks of driving or operating machinery if they do get drowsy. Similar to non-sedating antihistamines (above); however, these medicines can be quite sedating. May be useful when taken at night to improve sleep quality if itching is severe. Warn about the sedating effects and risks of driving or operating machinery while taking these medicines and to avoid alcohol (see Reference Section, OTC Medicine Precautions). Sedating antihistamines are [PRESCRIPTION ONLY MEDICINES] for children under two. Relieves localised itch and inflammation. Good for short-term use (two to three days) on small localised areas. Some people with sensitive skin may react to excipients in the cream and develop a contact dermatitis. Higher doses of vitamin C (ie, 1000mg) may help reduce histamine levels. Aloe vera has a cooling, soothing action. Products with an asterisk have a detailed listing in the Itchy Rash and Urticaria section of OTC Products, on page 266. PharmacyToday A part of your everyday Page 158 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Acute urticaria can also be caused by sunlight, heat, cold, water, pressure, vibration, or exercise. The trigger is not known or identified in about half of all cases. Chronic urticaria Chronic urticaria lasts more than six weeks and is often due to an autoinflammatory disease such as systemic lupus erythematosus. Referral to a doctor for an extensive review of the customer’s medical history, diagnostic tests and a thorough physical examination is necessary. Initial assessment Put on a pair of gloves and have a good look at the customer's urticaria. Ask about extent of spread and run through the Refer to Pharmacist questions and refer any "yes" answers to a pharmacist. Treatment The best treatment for urticaria is to identify and eliminate the cause if possible. Oral antihistamines are effective at relieving the itch and work best if taken on a regular schedule. Oral corticosteroids or other medicines (eg, antileukotriene agents) prescribed by a doctor may also provide relief and in severe cases an injection of adrenaline may be needed. Advice for customers • Avoid triggers for urticaria if known and if possible. • Dietary changes may help. Some urticaria is aggravated by salicyclates in certain fruits, or additives including amines, tartrazine (102), benzoates (210- 220) and other food chemicals. • Seek medical advice if certain medications appear to precipitate urticaria. Similar classes of medications may do the same thing. • Customers with urticaria should: »» avoid alcohol (it causes the surface blood vessels to dilate) »» avoid tight clothes as sweating and pressure may worsen symptoms »» cool the affected area with a fan, cold flannel, ice pack, or cream containing menthol; alternatively a tepid or cold shower may be soothing »» treat any pain with paracetamol »» see a doctor if the urticaria does not respond to an antihistamine, or persists more than a few days. Refer to PHARMACIST Seek urgent medical help if the person has any signs of facial swelling, or difficulty swallowing or breathing. In other cases of urticaria, ask the following questions to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication or herbal remedy, either prescribed by a doctor or bought from a shop? • Has the urticaria lasted longer than 24–48 hours? • Are there any blisters, crusting or pus associated with the urticaria? • Does the urticaria occur more often than just occasionally? • Does the urticaria cover a large area of the body? • Does the person have a fever or feel generally unwell? • Is the person a child under 12 years? • Have oral antihistamines been tried but the itch still persists? • Does the person have any allergies to medicines? SUBSCRIBE • Latest pharmacy headlines • Online learning • Hot retail tips • Prizes & giveaways • Healthcare Handbook 09 488 4286 www.pharmacytoday.co.nz Page 159

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