Chronic Idiopathic Urticaria: When Medications Aren't Enough

Health Professional

About one out of a thousand people in the U.S. suffer from chronic idiopathic urticaria (CIU). The number seems small, but when you consider the population of America we’re talking about 300,000 people. CIU is the diagnosis when people have hives occurring almost daily for six or more weeks. Some studies have tracked patients with CIU and reported more than 50 percent of them suffering from the condition for more the three years. A small percentage of patients may require treatment for more than a decade, but that's most of the bad news.

The good news is that doctors have learned about more treatment options for managing CIU over the last few years. I reviewed several of them in a recent posting.

CIU is one of several chronic conditions that can be either brought on by stress or cause stress. As such, the quality of life of individuals who have CIU is predictably impacted by being forced to cope with daily or almost daily itching, smelting, cosmetic embarrassment, or the fear of experiencing them. Severe CIU is associated with poor work or school performance, poor quality, of sleep, social isolation, increased depression and anxiety.

The diagnosis of CIU is often difficult to accept. Doctors identify a specific trigger or cause of chronic urticaria only ten to twenty percent of the time, and when they can't, CIU is the default diagnosis. Patients go to doctors looking for answers to one main question, “What is causing me to have hives?” Unfortunately in the setting of CIU, that's the one question doctors are unable to answer.

Besides dealing with the frustration of potentially debilitating skin eruptions, CIU patients must accept the need to take multiple medications two or more times daily. If the first trials of medication fail, stronger ones are recommended. This means higher risks of adverse drug effects and increased medication expenses. It's no wonder that CIU may cause despair and subsequent psychosocial problems when lasting for months to years. So, what can you do?

Coping with CIU is a challenge that is best met by first, having a clear understanding of the disease, how it is diagnosed, tracked and treated.

How is CIU diagnosed?

A thorough history and physical exam are all that is needed to make the diagnosis of CIU. The three major components to making the diagnosis are:

  1. Hives coming and going for six or more weeks

  2. No identifiable cause after evaluation and testing

  3. No underlying medical condition that may cause hives

Tracking CIU

Not all doctors are in agreement on how to track CIU, but one available method is to periodically assess the level of control by using the Urticaria Control Test (UCT). Similar to the Asthma Control Test (ACT) used to measure control of asthma, the CUT allows doctors to measure the degree of control of CIU over time.

Urticaria Control Test:

1)    How much have you suffered from the physical symptoms of the urticaria (itch, hives (welts) and or swelling) in the last four weeks?

1-very much                        2-much         3-somewhat                        4-a little         5-not at all

2)    How much was your quality of life affected by the urticaria in the last four weeks?

1-very much                        2-much         3-somewhat                        4-a little         5-not at all

3)    How often was treatment for your urticaria in the last four weeks not enough to control your urticaria symptoms?

1-very often                        2-often          3-sometimes            4-seldom      5-not at all

4)    Overall, how well have you had your urticaria under control in the last four weeks?

1-not at all                2-a little         3-somewhat                        4-well                        5-very well

A score of 11 or lower means urticaria is not under good control, and medications or the treatment plan should be reviewed.

Treatment of CIU

As mentioned (see the link) above, I posted a detailed report about treatment of CIU in a recent article. Antihistamines alone are helpful only about half the time. If signs of depression or anxiety are evident, proper counseling and treatments should be pursued. Psychological evaluation may uncover problems which preceded hives but escalated after they became prevalent. Group therapy and involvement in a support group may lower the need for prescription medications.

Final Words

CIU is a treatable disorder that may require a comprehensive evaluation and management plan. Allergists and dermatologists play a vital role in this process when daily antihistamines fall short of controlling the disorder. Psychosocial factors may surface as a result of having chronic hives, or complicate CIU by lowering the threshold for hives. Your doctor may refer you to a psychologist or psychiatrist for additional assistance in care. Don’t mistakenly consider the referral an attempt by your doctor to get rid of you, or blame your problem on nerves. Almost any chronic disease may be complicated by anxiety or depression.

References: Chronic Urticaria and Psychological Stress Chronic Urticaria: The importance of a medical-psychological approach

Other Suggested Readings: Making Progress in the Management of Chronic Urticaria Chronic Urticaria: A Dreadful Disorder that remains difficult to understand Diagnosing and Treating CIU