Acute and Chronic Urticaria: Understanding, Managing, and Treating the Condition

Urticaria, commonly known as hives, is a skin condition characterized by red, itchy welts that appear suddenly. It can manifest in two primary forms: acute and chronic. While acute urticaria typically lasts for a short duration and is often triggered by an allergic reaction, chronic urticaria persists for longer periods and may not have an identifiable cause. Understanding the differences between these two types, as well as their treatment options, is crucial for effective management.

What is Chronic Urticaria?

Chronic urticaria is a condition in which hives persist for six weeks or longer, often recurring for months or even years. It presents as raised, itchy welts that can appear on different parts of the body. Unlike acute urticaria, which is usually linked to allergens, chronic urticaria is often idiopathic, meaning no specific cause can be identified.

There are two main types of chronic urticaria. The first, known as chronic spontaneous urticaria (CSU), occurs without an obvious external trigger. This type is believed to have an autoimmune component in many cases. The second form, chronic inducible urticaria (CIndU), is triggered by specific physical stimuli such as temperature changes, pressure on the skin, exposure to sunlight, or even exercise. While CSU tends to appear unpredictably, CIndU follows a more defined pattern, with symptoms arising when the triggering factor is present.

People with chronic urticaria may experience periods of remission, but in some cases, symptoms persist for years. This unpredictability can significantly affect the quality of life, making effective treatment and management essential.

What is the difference between chronic and acute urticaria?

Acute and chronic urticaria differ primarily in duration, causes, and treatment approaches. Acute urticaria lasts less than six weeks and is usually linked to external factors such as allergens, infections, or medications. It often resolves on its own once the triggering substance is removed or treated. The hives in acute urticaria can be accompanied by angioedema, which causes swelling of the lips, eyelids, or other soft tissues.

Chronic urticaria, on the other hand, extends beyond the six-week mark and does not always have an identifiable trigger. In many cases, it is considered an autoimmune disorder, where the body mistakenly attacks its own skin cells, causing persistent inflammation. While acute urticaria can often be managed by avoiding allergens and using short-term medications, chronic urticaria requires a more complex approach that includes long-term antihistamine therapy and, in some cases, immunomodulatory treatments.

The unpredictability of chronic urticaria makes it more challenging to treat than acute urticaria. Many patients experience fluctuating symptoms, with periods of flare-ups and remissions. Unlike acute urticaria, which often resolves completely, chronic urticaria can persist for years and requires ongoing medical supervision.

Urticaria Management Guidelines

Effective management of urticaria depends on proper diagnosis, symptom control, and prevention of recurrence. The first step in managing urticaria is identifying potential triggers. A thorough medical history and examination help determine whether the condition is acute or chronic. In acute cases, recent exposure to allergens, medications, or infections is evaluated, while in chronic cases, autoimmune and other systemic conditions may be considered. Diagnostic tests such as blood work and allergy testing may be conducted if needed.

For treatment, non-sedating second-generation antihistamines such as loratadine, cetirizine, or fexofenadine are recommended as the first line of defense. These medications help control itching and prevent further hive formation. If symptoms persist despite regular antihistamine use, the dosage may be increased under medical supervision.

When antihistamines alone are insufficient, additional medications can be introduced. Leukotriene receptor antagonists, such as montelukast, provide an alternative option for some patients. In certain cases, H2-antihistamines, which are commonly used for acid reflux, are added to enhance symptom control. Short-term corticosteroids may be prescribed for severe flare-ups, though their long-term use is discouraged due to potential side effects.

For chronic urticaria that does not respond to conventional treatments, biologic therapy such as omalizumab (Xolair) offers a highly effective solution. This monoclonal antibody targets immunoglobulin E (IgE), reducing the immune response that contributes to hives. In severe and refractory cases, immunosuppressants like cyclosporine may be used, though they require careful monitoring due to their potential risks.

Lifestyle modifications also play a crucial role in urticaria management. Patients are advised to avoid known triggers, use gentle skincare products, and wear loose, breathable clothing. In cases where stress contributes to symptoms, relaxation techniques and stress management strategies can help reduce flare-ups.

Treatment of Urticaria with Periactin (Cyproheptadine)

Periactin, also known as cyproheptadine, is a first-generation antihistamine that has been used in the treatment of urticaria. Unlike newer antihistamines, which are non-sedating, Periactin has a sedative effect, making it particularly useful for patients who experience nighttime itching and difficulty sleeping due to their symptoms.

The mechanism of action of Periactin involves blocking histamine receptors, which helps reduce itching, swelling, and redness associated with urticaria. Additionally, it acts as a serotonin antagonist, which may provide additional benefits for individuals whose hives are triggered by stress or neurological factors. This dual action makes Periactin a unique choice among antihistamines, though its sedative properties can be a drawback for some patients.

In terms of dosage, Periactin is typically prescribed at a starting dose of 4 mg three times daily for adults, with adjustments based on individual response. The maximum daily dosage should not exceed 32 mg. For children, dosing is based on weight and age, with careful monitoring to avoid excessive sedation.

While Periactin is effective in controlling urticaria symptoms, it is not always the first choice for long-term management due to its side effects. Drowsiness and fatigue are common, which can interfere with daily activities. Other potential side effects include dry mouth, dizziness, and increased appetite, which can lead to weight gain.

Despite these drawbacks, Periactin remains a viable option for certain patients, particularly those who have not responded well to second-generation antihistamines. However, individuals with conditions such as glaucoma, peptic ulcer disease, or urinary retention should avoid this medication. Additionally, caution is advised for those taking central nervous system depressants, as Periactin can enhance their effects.

Conclusion

Urticaria, whether acute or chronic, is a distressing condition that requires careful management to ensure patient comfort and well-being. Acute urticaria is often linked to allergens or infections and usually resolves on its own, whereas chronic urticaria can persist for months or even years, often without a clear cause. Effective management involves a combination of antihistamines, lifestyle adjustments, and in severe cases, advanced therapies such as biologics or immunosuppressants.

For individuals seeking relief from urticaria symptoms, medications such as Periactin can be a valuable treatment option. While it is not the first choice for all patients, its antihistamine and serotonin-blocking effects make it particularly useful for those who struggle with sleep disturbances and antihistamine resistance.

Because chronic urticaria can significantly impact daily life, consulting a healthcare provider for a personalized treatment plan is essential. By following established management guidelines and utilizing appropriate treatments, patients can achieve better symptom control and improve their quality of life.

Medically Reviewed by Dr. Mevan Nandaka Wijetunga, MD