GUIDELINES FOR THE EVALUATION AND MANAGEMENT OF PATIENTS WHO PRESENT WITH “CHRONIC URTICARIA: AN EVIDENCE-BASED ALGORITHM AND ANALYSIS
Location
Medical Education Building, LSUHSC-NO
Presentation Date
10-10-2019 10:00 AM
End Date
10-10-2019 12:00 PM
Description
Background: Chronic urticaria is a common cutaneous condition that dermatologists are called on to manage. In addition to evaluating the patient for chronic urticaria, dermatologists should be aware of the entities that may mimic chronic urticaria. We aimed to define those entities and present an approach to the patient who presents with urticarial lesions, but upon further investigation, is diagnosed with a condition other than chronic urticaria. Methods: Literature Search. A systematic review of available English-language, peer-reviewed literature was conducted using the following electronic databases to identify pertinent publications: PubMed/MEDLINE, Google Scholar, EMBASE, and the Cochrane Database of Systematic Reviews. The articles were individually screened for relevance based on their titles, abstracts, and full texts. Results: A patient that presents to clinic with urticarial lesions must be carefully evaluated. The dermatologist must pay attention to pertinent signs in the history, physical, and response to treatment that may indicate a diagnosis other than chronic urticaria. Signs inconsistent with a diagnosis of chronic urticaria indicate the need for skin biopsy. Based on the results, the patient is evaluated for a diagnosis within the differential diagnosis of neutrophilic infiltrate with vasculitis or neutrophilic infiltrate without vasculitis. Biopsies resulting in infiltrate with neutrophil predominance leads to a differential diagnosis that includes neutrophilic urticaria, neutrophilic urticaria with systemic inflammation (NUSI), rheumatic fever, adult-onset still’s disease, cryopyrin-associated periodic syndrome, Schnitzler syndrome, and mevalonate kinase deficiency. Skin biopsy resulting in neutrophil dominated infiltrate with vasculitis leads to a different group of disorders characterized by clinical features of urticarial lesions with pathology demonstrating leukocytoclastic vasculitis: normocomplementemic urticarial vasculitis (NUV) and hypocomplementemic urticarial vasculitis (HUV). Diagnosis is confirmed by the specific diagnostic criteria for each condition. Treatment often includes antimicrobial and anti-inflammatory agents with antineutrophil effects, such as colchicine and dapsone, in combination with immunomodulators. Conclusion: We have provided a comprehensive workup and an evidence-based algorithm to assist the clinician when evaluating and managing patients who presents with urticarial lesions and symptoms inconsistent with a classic diagnosis of chronic urticaria. This will help minimize the chance of misdiagnosis and will ultimately lead to effective treatment for these patients.
Recommended Citation
Fox, Lindy MD and Robertson, Chelsi BS, "GUIDELINES FOR THE EVALUATION AND MANAGEMENT OF PATIENTS WHO PRESENT WITH “CHRONIC URTICARIA: AN EVIDENCE-BASED ALGORITHM AND ANALYSIS" (2019). Medical Student Research Poster Symposium. 35.
https://digitalscholar.lsuhsc.edu/sommrd/2019/posters/35
GUIDELINES FOR THE EVALUATION AND MANAGEMENT OF PATIENTS WHO PRESENT WITH “CHRONIC URTICARIA: AN EVIDENCE-BASED ALGORITHM AND ANALYSIS
Medical Education Building, LSUHSC-NO
Background: Chronic urticaria is a common cutaneous condition that dermatologists are called on to manage. In addition to evaluating the patient for chronic urticaria, dermatologists should be aware of the entities that may mimic chronic urticaria. We aimed to define those entities and present an approach to the patient who presents with urticarial lesions, but upon further investigation, is diagnosed with a condition other than chronic urticaria. Methods: Literature Search. A systematic review of available English-language, peer-reviewed literature was conducted using the following electronic databases to identify pertinent publications: PubMed/MEDLINE, Google Scholar, EMBASE, and the Cochrane Database of Systematic Reviews. The articles were individually screened for relevance based on their titles, abstracts, and full texts. Results: A patient that presents to clinic with urticarial lesions must be carefully evaluated. The dermatologist must pay attention to pertinent signs in the history, physical, and response to treatment that may indicate a diagnosis other than chronic urticaria. Signs inconsistent with a diagnosis of chronic urticaria indicate the need for skin biopsy. Based on the results, the patient is evaluated for a diagnosis within the differential diagnosis of neutrophilic infiltrate with vasculitis or neutrophilic infiltrate without vasculitis. Biopsies resulting in infiltrate with neutrophil predominance leads to a differential diagnosis that includes neutrophilic urticaria, neutrophilic urticaria with systemic inflammation (NUSI), rheumatic fever, adult-onset still’s disease, cryopyrin-associated periodic syndrome, Schnitzler syndrome, and mevalonate kinase deficiency. Skin biopsy resulting in neutrophil dominated infiltrate with vasculitis leads to a different group of disorders characterized by clinical features of urticarial lesions with pathology demonstrating leukocytoclastic vasculitis: normocomplementemic urticarial vasculitis (NUV) and hypocomplementemic urticarial vasculitis (HUV). Diagnosis is confirmed by the specific diagnostic criteria for each condition. Treatment often includes antimicrobial and anti-inflammatory agents with antineutrophil effects, such as colchicine and dapsone, in combination with immunomodulators. Conclusion: We have provided a comprehensive workup and an evidence-based algorithm to assist the clinician when evaluating and managing patients who presents with urticarial lesions and symptoms inconsistent with a classic diagnosis of chronic urticaria. This will help minimize the chance of misdiagnosis and will ultimately lead to effective treatment for these patients.