| What is a distinguishing feature of a wheal in urticaria? | A sharply circumscribed superficial central swelling of variable size and shape, surrounded by reflex erythema | • Urticaria -sudden appearance of wheals, angioedema, or both • A wheal- A sharply circumscribed superficial central swelling of variable size and shape, surrounded by reflex erythema > Associated with itching / burning sensation and of fleeting nature- resolves within 1–24 hours > Chronic urticaria implies duration for more than 6 weeks • Angioedema > Sudden, pronounced, erythematous or skin-colored swelling of lower dermis and subcutis with frequent involvement of mucous membranes > Associated pain, rather than itching /resolution is slower and can take up to 72 hours • Time to onset • Frequency / duration • Diurnal variation • Associated angioedema • Associated pain, itch • Induction by physical agents or exercise • Family history • Previous allergies • Surgical implantations • Gastric / intestinal problem • Due to evanescent nature the examination may not show any lesions • Presence of wheals of various sizes and shapes • The lesions are non-scaly but show an intense erythema and a trailing clearing region in older areas which may lead to a target configuration in expanding plaques • Drug history • Correlation with food • Correlation with menses • Smoking • Work profile • Hobbies • Stress • Quality of life impact • Response to therapy | 73 | definition | 1.000 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | • Urticaria -sudden appearance of wheals, angioedema, or both • A wheal- A sharply circumscribed superficial central swelling of variable size and shape, surrounded by reflex erythema > Associated with itching / burning sensation and of fleeting nature- resolves within 1–24 hours > Chronic urticaria implies duration for more than 6 weeks • Angioedema > Sudden, pronounced, erythematous or skin-colored swelling of lower dermis and subcutis with frequent involvement of mucous membranes > Associated pain, rather than itching /resolution is slower and can take up to 72 hours • Time to onset • | 1 | page=1,block=6 | 0.700 | valid |
| What is a characteristic feature of urticarial vasculitis? | painful, persist for 24-48 hours and fade to leave bruising; ± fever and arthralgia | (presenting with wheals, angioedema, or both) Inducible (mostly physical) • Spontaneous appearance of wheals, angioedema, or both for ≥6 weeks • Symptomatic dermographism • Delayed pressure urticaria • Cholinergic urticaria • Cold/Heat urticaria • Solar urticaria • Aquagenic urticaria • Contact urticaria • Insect /Bedbug bites • Urticarial vasculitis- painful, persist for 24-48 hours and fade to leave bruising; ± fever and arthralgia • Pre bullous phase of bullous pemphigoid • Maculopapular drug/ viral rash INVESTIGATIONS Generally, no investigations are needed to confirm the diagnosis • Skin biopsy may be indicated if other diagnoses are being suspected • C4 and C1 inhibitor quantitation to detect C1 inhibitor deficiency may be done in suspected hereditary angioedema (Angioedema without urticaria) • Tests for current or past viral, bacterial or parasitic infections should be guided by history and clinical findings • Lab tests may be needed if patient is planned for immunosuppressive treatment • Certain investigations that are often ordered, but are of limited utility > Thyroid function tests and antithyroid peroxidase (TPO) antibodies > Autologous serum skin test (ASST) > Skin prick / specific IgE test | 354 | summary | 0.970 |
| What is the reassurance provided to patients regarding the use of long-acting antihistamines? | prolonged treatment with long-acting, non-sedating antihistamines is not harmful | • Reassure -remits spontaneously in 12-24 months in ~50% patients • Treat with antihistamines. Reassure that prolonged treatment with long-acting, non-sedating antihistamines is not harmful • Non-sedating antihistamines (e.g. Cetirizine 10mg, Levocetirizine 5mg, Loratadine 10mg, or Fexofenadine 180mg once daily) mainstay of treatment. Dose can be increased 4-fold safely if needed • Long-term first generation antihistamines e.g. | 109 | summary | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | Reassure that prolonged treatment with long-acting, non-sedating antihistamines is not harmful • Non-sedating antihistamines (e.g. | 1 | page=1,block=50 | 0.700 | valid |
| What symptoms are associated with angioedema that differentiate it from wheals? | Associated pain, rather than itching | • Urticaria -sudden appearance of wheals, angioedema, or both • A wheal- A sharply circumscribed superficial central swelling of variable size and shape, surrounded by reflex erythema > Associated with itching / burning sensation and of fleeting nature- resolves within 1–24 hours > Chronic urticaria implies duration for more than 6 weeks • Angioedema > Sudden, pronounced, erythematous or skin-colored swelling of lower dermis and subcutis with frequent involvement of mucous membranes > Associated pain, rather than itching /resolution is slower and can take up to 72 hours • Time to onset • Frequency / duration • Diurnal variation • Associated angioedema • Associated pain, itch • Induction by physical agents or exercise • Family history • Previous allergies • Surgical implantations • Gastric / intestinal problem • Due to evanescent nature the examination may not show any lesions • Presence of wheals of various sizes and shapes • The lesions are non-scaly but show an intense erythema and a trailing clearing region in older areas which may lead to a target configuration in expanding plaques • Drug history • Correlation with food • Correlation with menses • Smoking • Work profile • Hobbies • Stress • Quality of life impact • Response to therapy | 490 | comparison |
| What should be avoided in patients with a history of drug-induced urticaria or angioedema? | drugs such as NSAIDs, PCM, ACE inhibitors | Chlorphenamine, Hydroxyzine avoided if possible due to risk of sedation and psychomotor impairment • Avoid triggers including drugs such as NSAIDs, PCM, ACE inhibitors if history is suggestive of drug induced or exacerbated urticaria/ angioedema TREATMENT • Severe urticaria with respiratory distress- maintain airway; injectable Hydrocortisone and Pheniramine (Avil) may be required • Intra-muscular Adrenaline of 1:1000 dilution (1 mg in 1 mL), 0.2 to 0.5 mg (0.01 mg/kg in children; maximum dose: 0.3 mg) administered intramuscularly every 5 to 15 minutes if choking/respiratory distress/shock * Angioedema with respiratory or laryngeal symptom requires emergency management -refer to higher center after vital stabilization; oral Prednisolone may be initiated to take care of biphasic response | 126 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | Chlorphenamine, Hydroxyzine avoided if possible due to risk of sedation and psychomotor impairment • Avoid triggers including drugs such as NSAIDs, PCM, ACE inhibitors if history is suggestive of drug induced or exacerbated urticaria/ angioedema TREATMENT • Severe urticaria with respiratory distress- maintain airway; injectable Hydrocortisone and Pheniramine (Avil) may be required • Intra-muscular Adrenaline of 1:1000 dilution (1 mg in 1 mL), 0.2 to 0.5 mg (0.01 mg/kg in children; maximum dose: 0.3 mg) administered intramuscularly every 5 to 15 minutes if choking/respiratory distress/shock * |
| What type of urticaria is triggered by temperature changes? | Cold/Heat urticaria | (presenting with wheals, angioedema, or both) Inducible (mostly physical) • Spontaneous appearance of wheals, angioedema, or both for ≥6 weeks • Symptomatic dermographism • Delayed pressure urticaria • Cholinergic urticaria • Cold/Heat urticaria • Solar urticaria • Aquagenic urticaria • Contact urticaria • Insect /Bedbug bites • Urticarial vasculitis- painful, persist for 24-48 hours and fade to leave bruising; ± fever and arthralgia • Pre bullous phase of bullous pemphigoid • Maculopapular drug/ viral rash INVESTIGATIONS Generally, no investigations are needed to confirm the diagnosis • Skin biopsy may be indicated if other diagnoses are being suspected • C4 and C1 inhibitor quantitation to detect C1 inhibitor deficiency may be done in suspected hereditary angioedema (Angioedema without urticaria) • Tests for current or past viral, bacterial or parasitic infections should be guided by history and clinical findings • Lab tests may be needed if patient is planned for immunosuppressive treatment • Certain investigations that are often ordered, but are of limited utility > Thyroid function tests and antithyroid peroxidase (TPO) antibodies > Autologous serum skin test (ASST) > Skin prick / specific IgE test | 226 | list | 0.740 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf |
| What dosage adjustment is suggested for second-line treatment of urticaria? | Increase dosage (upto fourfold) of 2nd generation antihistamines | • Patients whose urticaria is difficult to control with antihistamines despite fourfold higher dosage than the licensed doses of Cetirizine, Levocetirizine or Fexofenadine • Patients with polypharmacy • Unusual urticaria e.g. long lasting lesions >24-48 hours with bruising • Associate angioedema that is unresponsive or presents with choking/ dyspnoea • Investigations not available First Line: 2nd generation non-sedating antihistamines Second Line: Increase dosage (upto fourfold) of 2nd generation antihistamines Refer to higher centre If symptoms persist after 2 weeks If symptoms persist after 2–4 further weeks | 452 | factual | 0.570 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | long lasting lesions >24-48 hours with bruising • Associate angioedema that is unresponsive or presents with choking/ dyspnoea • Investigations not available First Line: 2nd generation non-sedating antihistamines Second Line: Increase dosage (upto fourfold) of 2nd generation antihistamines Refer to higher centre If symptoms persist after 2 weeks If symptoms persist after 2–4 further weeks | 1 |
| What is the mainstay of treatment for urticaria? | Non-sedating antihistamines (e.g. Cetirizine 10mg, Levocetirizine 5mg, Loratadine 10mg, or Fexofenadine 180mg once daily) | • Reassure -remits spontaneously in 12-24 months in ~50% patients • Treat with antihistamines. Reassure that prolonged treatment with long-acting, non-sedating antihistamines is not harmful • Non-sedating antihistamines (e.g. Cetirizine 10mg, Levocetirizine 5mg, Loratadine 10mg, or Fexofenadine 180mg once daily) mainstay of treatment. Dose can be increased 4-fold safely if needed • Long-term first generation antihistamines e.g. | 192 | factual | 0.570 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | Reassure that prolonged treatment with long-acting, non-sedating antihistamines is not harmful • Non-sedating antihistamines (e.g. Cetirizine 10mg, Levocetirizine 5mg, Loratadine 10mg, or Fexofenadine 180mg once daily) mainstay of treatment. | 1 | page=1,block=50 | 0.700 | valid |
| What is the maximum duration for a short course of corticosteroids in the treatment plan? | max 10 days | Add third line on to second line: Cyclosporine A (3-5 mg/Kg) or Montelukast (10 mg HS) Short course (max 10 days) of corticosteroids (Prednisolone-0.3-0.5 mg/kg)# Third line: Add on to second line Omalizumab (300mg s/c every 4 weeks) or Cyclosporine A or Montelukast Short course (max 10 days) of corticosteroids # #Oral or injectable conticosteroids are generally not used, except in uncontrolled disease or with associated respiratory symtoms | 101 | factual | 0.490 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | Add third line on to second line: Cyclosporine A (3-5 mg/Kg) or Montelukast (10 mg HS) Short course (max 10 days) of corticosteroids (Prednisolone-0.3-0.5 mg/kg)# Third line: Add on to second line Omalizumab (300mg s/c every 4 weeks) or Cyclosporine A or Montelukast Short course (max 10 days) of corticosteroids # #Oral or injectable conticosteroids are generally not used, except in uncontrolled disease or with associated respiratory symtoms | 1 | page=1,block=81 | 0.700 | valid |
| What should be done if urticaria symptoms persist after two weeks of treatment? | Refer to higher centre | • Patients whose urticaria is difficult to control with antihistamines despite fourfold higher dosage than the licensed doses of Cetirizine, Levocetirizine or Fexofenadine • Patients with polypharmacy • Unusual urticaria e.g. long lasting lesions >24-48 hours with bruising • Associate angioedema that is unresponsive or presents with choking/ dyspnoea • Investigations not available First Line: 2nd generation non-sedating antihistamines Second Line: Increase dosage (upto fourfold) of 2nd generation antihistamines Refer to higher centre If symptoms persist after 2 weeks If symptoms persist after 2–4 further weeks | 517 | factual | 0.490 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725967365_urticaria_and_angioedema.pdf | long lasting lesions >24-48 hours with bruising • Associate angioedema that is unresponsive or presents with choking/ dyspnoea • Investigations not available First Line: 2nd generation non-sedating antihistamines Second Line: Increase dosage (upto fourfold) of 2nd generation antihistamines Refer to higher centre If symptoms persist after 2 weeks If symptoms persist after 2–4 further weeks | 1 | page=1,block=57 |