Sunday, May 5, 2013
Thursday, April 4, 2013
HFMD
Hand-foot-mouth disease
Hand-foot-mouth disease is a relatively common infection viral infection that usually begins in the throat.
A similar infection is herpangina.
Causes
Hand-foot-and-mouth disease (HFMD) is most commonly caused by coxsackievirus A16, a member of the enterovirus family.
The disease is not spread from pets, but it can be spread by person to person. You may catch it if you come into direct contact with nose and throat discharges, saliva, fluid from blisters, or the stools of an infected person. You are most contagious the first week you have the disease.
The time between infection and the development of symptoms is about 3 - 7 days.
The most important risk factor is age. The infection occurs most often in children under age 10, but can be seen in adolescents and occasionally adults. The outbreaks occur most often in the summer and early fall.
Symptoms
Fever
Headache
Loss of appetite
Rash with very small blisters on hands, feet, and diaper area; may be tender or painful if pressed
Sore throat
Ulcers in the throat (including tonsils), mouth, and tongue
Exams and Tests
A history of recent illness and a physical examination, demonstrating the characteristic vesicles on the hands and feet, are usually sufficient to diagnose the disease.
Treatment
There is no specific treatment for the infection other than relief of symptoms.
Treatment with antibiotics does not work and is not recommended. Over-the-counter medicines, such as acetaminophen (Tylenol) or ibuprofen can be used to treat fever. Aspirin should not be used in viral illnesses in children under age 12 years.
Salt water mouth rinses (1/2 teaspoon of salt to 1 glass of warm water) may be soothing if the child is able to rinse without swallowing. Make sure your child gets plenty of fluids. Extra fluid is needed when a fever is present. The best fluids are cold milk products. Many children refuse juices and sodas because their acid content causes burning pain in the ulcers.
Outlook (Prognosis)
Generally, complete recovery occurs in 5 to 7 days.
Possible Complications
Dehydration
Febrile seizures
When to Contact a Medical Professional
Call your health care provider if there are signs of complications, such as pain in neck or arms and legs. Emergency symptoms include convulsions.
You should also call if:
Medicine does not lower a high fever
Signs of dehydration occur:
Dry skin and mucus membranes
Weight loss
Irritability
Lethargy
Decreased or dark urine
Prevention
Avoid contact with people with known illness. Always wash your hands well and often, especially if you are in contact with people who are sick.
Alternative Names
Coxsackievirus infection
Hand-foot-mouth disease is a relatively common infection viral infection that usually begins in the throat.
A similar infection is herpangina.
Causes
Hand-foot-and-mouth disease (HFMD) is most commonly caused by coxsackievirus A16, a member of the enterovirus family.
The disease is not spread from pets, but it can be spread by person to person. You may catch it if you come into direct contact with nose and throat discharges, saliva, fluid from blisters, or the stools of an infected person. You are most contagious the first week you have the disease.
The time between infection and the development of symptoms is about 3 - 7 days.
The most important risk factor is age. The infection occurs most often in children under age 10, but can be seen in adolescents and occasionally adults. The outbreaks occur most often in the summer and early fall.
Symptoms
Fever
Headache
Loss of appetite
Rash with very small blisters on hands, feet, and diaper area; may be tender or painful if pressed
Sore throat
Ulcers in the throat (including tonsils), mouth, and tongue
Exams and Tests
A history of recent illness and a physical examination, demonstrating the characteristic vesicles on the hands and feet, are usually sufficient to diagnose the disease.
Treatment
There is no specific treatment for the infection other than relief of symptoms.
Treatment with antibiotics does not work and is not recommended. Over-the-counter medicines, such as acetaminophen (Tylenol) or ibuprofen can be used to treat fever. Aspirin should not be used in viral illnesses in children under age 12 years.
Salt water mouth rinses (1/2 teaspoon of salt to 1 glass of warm water) may be soothing if the child is able to rinse without swallowing. Make sure your child gets plenty of fluids. Extra fluid is needed when a fever is present. The best fluids are cold milk products. Many children refuse juices and sodas because their acid content causes burning pain in the ulcers.
Outlook (Prognosis)
Generally, complete recovery occurs in 5 to 7 days.
Possible Complications
Dehydration
Febrile seizures
When to Contact a Medical Professional
Call your health care provider if there are signs of complications, such as pain in neck or arms and legs. Emergency symptoms include convulsions.
You should also call if:
Medicine does not lower a high fever
Signs of dehydration occur:
Dry skin and mucus membranes
Weight loss
Irritability
Lethargy
Decreased or dark urine
Prevention
Avoid contact with people with known illness. Always wash your hands well and often, especially if you are in contact with people who are sick.
Alternative Names
Coxsackievirus infection
Hand foot mouth disease
Hand, foot and mouth disease
Not to be confused with Foot-and-mouth disease.
Hand, foot and mouth disease (HFMD) is a human syndrome caused by intestinal viruses of the picornaviridae family. The most common strains causing HFMD are coxsackie A virus and enterovirus 71 (EV-71).
HFMD usually affects infants and children, and is quite common. It is moderately contagious and is spread through direct contact with the mucus, saliva, or feces of an infected person. It typically occurs in small epidemics in nursery schools or kindergartens, usually during the summer and autumn months. The usual incubation period is 3–7 days.
It is less common in adults, but those with immune deficiencies are very susceptible. HFMD is not to be confused with foot-and-mouth disease (also called hoof-and-mouth disease), which is a separate disease affecting sheep, cattle, and swine (both are caused by members of the picornaviridae family, but are not trans-communicable between humans and livestock).
Symptoms of HFMD include
Fever
Headache
Fatigue
Malaise
Referred ear pain
Sore throat
Painful oral, nasal, or facial lesions, ulcers or blisters
Body rash, followed by sores with blisters on palms of hand, soles of feet, and sometimes on the lips. The rash is rarely itchy for children, but can be extremely itchy for adults
Sores or blisters may be present on the buttocks of small children and infants
Irritability in infants and toddlers
Loss of appetite.
Diarrhea
The common incubation period (the time between infection and onset of symptoms) is from three to seven days.
Early symptoms are likely to be fever often followed by a sore throat. Loss of appetite and general malaise may also occur. Between one and two days after the onset of fever, painful sores (lesions) may appear in the mouth or throat, or both. A rash may become evident on the hands, feet, mouth, tongue, inside of the cheeks, and occasionally the buttocks (but generally, the rash on the buttocks will be caused by the diarrhea).
Treatment
There is no specific treatment for hand, foot and mouth disease. Individual symptoms, such as fever and pain from the sores, may be eased with the use of analgesics. HFMD is a viral disease that has to run its course; many doctors do not prescribe medicine for this illness. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, occasionally longer. Fever reducers and luke-warm baths can help bring temperature down.
Only a very small minority of sufferers require hospital admission, mainly as a result of uncommon neurological complications (encephalitis, meningitis, or acute flaccid paralysis) or pulmonary edema/pulmonary hemorrhage.
Complications
Complications from the virus infections that cause HFMD are not common, but if they do occur, medical care should be sought.
Viral or aseptic meningitis can rarely occur with HFMD. Viral meningitis causes fever, headache, stiff neck, or back pain. The condition is usually mild and clears without treatment; however, some patients may need to be hospitalized for a short time.
Other more serious diseases, such as encephalitis (swelling of the brain), a polio-like paralysis, result even more rarely. Encephalitis can be fatal.
There have been reports of fingernail and toenail loss occurring mostly in children within 4 weeks of their having hand, foot, and mouth disease (HFMD). At this time, it is not known whether the reported nail loss is or is not a result of the infection. However, in the reports reviewed, the nail loss has been temporary and nail growth resumed without medical treatment.[4]
Not to be confused with Foot-and-mouth disease.
Hand, foot and mouth disease (HFMD) is a human syndrome caused by intestinal viruses of the picornaviridae family. The most common strains causing HFMD are coxsackie A virus and enterovirus 71 (EV-71).
HFMD usually affects infants and children, and is quite common. It is moderately contagious and is spread through direct contact with the mucus, saliva, or feces of an infected person. It typically occurs in small epidemics in nursery schools or kindergartens, usually during the summer and autumn months. The usual incubation period is 3–7 days.
It is less common in adults, but those with immune deficiencies are very susceptible. HFMD is not to be confused with foot-and-mouth disease (also called hoof-and-mouth disease), which is a separate disease affecting sheep, cattle, and swine (both are caused by members of the picornaviridae family, but are not trans-communicable between humans and livestock).
Symptoms of HFMD include
Fever
Headache
Fatigue
Malaise
Referred ear pain
Sore throat
Painful oral, nasal, or facial lesions, ulcers or blisters
Body rash, followed by sores with blisters on palms of hand, soles of feet, and sometimes on the lips. The rash is rarely itchy for children, but can be extremely itchy for adults
Sores or blisters may be present on the buttocks of small children and infants
Irritability in infants and toddlers
Loss of appetite.
Diarrhea
The common incubation period (the time between infection and onset of symptoms) is from three to seven days.
Early symptoms are likely to be fever often followed by a sore throat. Loss of appetite and general malaise may also occur. Between one and two days after the onset of fever, painful sores (lesions) may appear in the mouth or throat, or both. A rash may become evident on the hands, feet, mouth, tongue, inside of the cheeks, and occasionally the buttocks (but generally, the rash on the buttocks will be caused by the diarrhea).
Treatment
There is no specific treatment for hand, foot and mouth disease. Individual symptoms, such as fever and pain from the sores, may be eased with the use of analgesics. HFMD is a viral disease that has to run its course; many doctors do not prescribe medicine for this illness. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, occasionally longer. Fever reducers and luke-warm baths can help bring temperature down.
Only a very small minority of sufferers require hospital admission, mainly as a result of uncommon neurological complications (encephalitis, meningitis, or acute flaccid paralysis) or pulmonary edema/pulmonary hemorrhage.
Complications
Complications from the virus infections that cause HFMD are not common, but if they do occur, medical care should be sought.
Viral or aseptic meningitis can rarely occur with HFMD. Viral meningitis causes fever, headache, stiff neck, or back pain. The condition is usually mild and clears without treatment; however, some patients may need to be hospitalized for a short time.
Other more serious diseases, such as encephalitis (swelling of the brain), a polio-like paralysis, result even more rarely. Encephalitis can be fatal.
There have been reports of fingernail and toenail loss occurring mostly in children within 4 weeks of their having hand, foot, and mouth disease (HFMD). At this time, it is not known whether the reported nail loss is or is not a result of the infection. However, in the reports reviewed, the nail loss has been temporary and nail growth resumed without medical treatment.[4]
Monday, March 11, 2013
Constipation in children
Constipation is a very common problem for children. For most children, constipation means passing hard poo (faeces, stools or motions), with difficulty, less often than normal. Regular soiling (often mistaken for runny diarrhoea) may indicate that a child has bad constipation with impaction (a blockage of faeces). Where no particular disease or illness is the cause of the constipation, it is called idiopathic constipation. It is important that constipation be recognised early to prevent it from becoming a long-term (chronic) problem.
Your child's bowels - what is normal?
Parents often get very worried about their child's bowel habit. This anxiety can start when the child is a baby, with concern over the number of dirty nappies. The main thing to realise is that every child is different. Normal can vary quite a bit. It is a change in what is normal for your child, that suggests a problem.
Babies will open their bowels anything from several times per day, to once every few days. The frequency of bowel movements is not very important. What is important is that the poo (faeces, stools or motions) is soft and easily passed.
Breast-fed babies tend to pass runnier, mustard yellow-coloured stools. This is because breast milk is better digested than infant formula (bottle feeds). Newborn breast-fed babies may open their bowels with every feed. However, it is also normal for a breast-fed baby to go up to a week without a bowel movement.
Bottle-fed babies often need to open their bowels daily, as the stools are bulkier. Bottle-fed baby stools smell worse (more like an adult's).
It is not uncommon for your baby's stools to vary in colour and consistency from day to day. Any prolonged change to harder, less frequent stools might mean constipation.
As babies are weaned to solid foods, their stools will change in colour and smell. The frequency may again change. Generally, the stools become thicker, darker and a lot more smelly. You will notice that your baby's stools will alter depending upon what you have fed him or her. Some high-fibre foods, such as raisins, may even pass through your baby's bowels virtually unchanged, appearing in the nappy at the next change.
As your baby grows up, into a toddler and then a young child, you may see further changes in their stool frequency and consistency, often dependent on what they are eating.
Your child's bowels - what is abnormal?
As you can see, there is great variation in a child's bowel habit, dependent on their age and what they are fed. As already mentioned, it is a change in what is normal for your child, that suggests a problem. Anything from three times a day to once every other day is common and normal. Less often than every other day means that constipation is likely. However, it can still be normal if the stools are soft and well formed, and passed easily.
It may be normal for your baby to go a bit red in the face when straining to pass a stool. Constipation is more of a problem than this. Breast-fed babies seldom get constipated, as breast milk contains exactly the right balance of nutrients to keep the stools soft and easily passed.
Diarrhoea usually means very runny stools, often passed more frequently than normal. Breast-fed babies get diarrhoea less frequently than other babies, as breast milk has a protective effect against the germs that can cause diarrhoea.
What is constipation?
Constipation in children or babies can mean any, or all, of the following:
Difficulty or straining when passing stools.
Pain when passing stools, sometimes with a tiny amount of blood in the nappy or on the toilet paper, due to a small tear in the skin of the back passage (anus).
Passing stools less often than normal. Generally, this is less than three complete (proper) stools per week.
Stools that are hard, and perhaps very large, or pellet-like and small, like rabbit droppings.
Other symptoms of constipation
As well as less frequent, hard (and perhaps painful) stools, constipation can cause:
Tummy ache (abdominal pain).
Poor appetite.
General malaise (feeling 'off colour').
Behavioural changes, such as being more irritable or unhappy.
Fidgeting, restlessness and other signs that the child needs to go to the toilet.
Feeling sick (nausea).
Severe constipation can cause impaction (where a very large stool is stuck in the rectum). This can cause further symptoms. In particular, this can cause a child to soil their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea. Impaction is discussed in detail later.
Types of constipation in children and babies
Idiopathic constipation. This is common. The word idiopathic means of unknown cause. Various factors may be involved (discussed later), but many children become constipated for no known reason.
Short bouts of constipation. It is common for children and babies to have a bout of mild constipation for a day or so. This may settle quickly, often without the need for medical treatment.
Long-term constipation. In about 1 in 3 children who become constipated, the problem becomes more long-term (persistent). This is also called chronic idiopathic constipation.
Constipation due to an underlying disease or condition. This is uncommon. The constipation is said to be secondary to this other problem. Some examples of conditions and problems that can cause constipation are:
Some neurological conditions.
An underactive thyroid gland (hypothyroidism).
Cystic fibrosis.
Rare diseases with abnormal development of the bowel, such as Hirschsprung's disease.
As a side-effect of certain medications that a child has to take for another condition.
Treatment may involve treating the underlying condition (if that is possible) in addition to tackling the constipation. Worrying symptoms or signs that may indicate a secondary cause include the following. These should be mentioned to your GP. It is also possible that some of these symptoms could mean your child is more seriously unwell:
Being sick (vomiting).
Weight loss or failure to gain weight (thrive).
A swollen, stretched tummy.
Severe pain.
A baby that does not pass its first stool (called meconium) within the first 48 hours of life.
Abnormalities of the back passage (anus) - for example, if it is closed over.
Nervous system (neurological) problems such as weak or paralysed legs.
Sores or ulcers near the anus.
Excessive thirst.
Urinary symptoms - such as passing huge volumes of urine, urine that is very dark or painful urination with smelly urine.
Very pale-coloured stools (especially if the urine is very dark too).
The rest of this leaflet is about idiopathic constipation.
Does my child need any tests?
Tests are not normally needed to diagnose idiopathic constipation. Your GP is likely to ask various questions and do a general examination to rule out secondary causes of constipation. By examining your child's tummy (abdomen), a GP can tell if there are lots of stools in the bowel. This can give an indication if blockage (impaction - discussed later) has developed. (If an underlying cause of constipation is suspected, your GP will refer your child to a children's doctor (a paediatrician) and further tests may be done.)
What causes idiopathic constipation?
Idiopathic means that there is no disease or known cause for the constipation. However, it is thought that various factors may contribute to constipation developing, or make it worse. These include diet, stool holding and emotional factors.
Diet
Dietary factors that may play a part in constipation are:
Not eating enough foods with fibre (the roughage part of the food that is not digested and stays in the gut).
Not having enough to drink.
Stools tend to become harder, drier, and more difficult to pass if there is little fibre and fluid in the gut.
Stool holding
This means the child has the feeling of needing the toilet, but resists it. The child holds on to the stool, trying to ignore the desire to empty the bowels. This is quite common. You may see your child crossing their legs, sitting on the back of the heels, or doing similar things to help resist the feeling of needing the toilet. Your child may clench his or her buttocks to try to stop the stool from coming out, and may seem quite fidgety. You may notice smudges of stool on your child's pants, often when they are unable to hold on any longer. The longer the child holds on, the bigger the stool gets. Eventually the child has to go, but the large stool is more difficult to pass, and often more painful. This may lead to a bit of a vicious cycle where the child is even more reluctant to open his or her bowels the next time. There are a number of reasons why children may hold on to stools:
A previous stool that they passed may have been a struggle or painful. So, they try to put off doing it again.
Their back passage (anus) may be sore or have a crack (anal fissure) from passing a previous large stool. It is then painful to pass further stools. So, the child may resist the urge to pass a stool.
They may have a dislike of unfamiliar or smelly toilets, such as at school or on holiday. The child may want to put things off until they get home.
Emotional problems
Constipation problems may be made worse with upset due to change in surroundings or routine. Common examples are moving house and starting nursery. Potty training may be a factor if a child becomes scared of using the potty. Fears and phobias are usually the underlying reasons for these problems.
What is idiopathic constipation with impaction?
Impaction means that the bowel is, in effect, blocked by a large amount of hard stool. Idiopathic constipation with impaction most commonly develops in children between the ages of 2 and 4 years, but older or younger children can be affected. Symptoms and features include:
Recurrent episodes when the child is uncomfortable or distressed trying to pass a stool.
The child soils their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea.
The child may also become irritable, not eat much, feel sick, have tummy pains from time to time, and may be generally out of sorts.
A doctor can often feel a backlog of hard, lumpy stools when he or she examines the child's tummy (abdomen).
The diagram below shows how a child may develop impaction, and the symptoms this may cause.
Normally, stools build up in the lowest part of the bowel.
When stools accumulate, they start to pass into the last part of the bowel (the rectum), which stretches. This sends nerve messages to the brain, telling you that you need to empty your bowels.
If the stool is not passed out then more stools from higher up also reach the rectum.
Eventually, large hard stools may build up in the rectum.
The rectum may then stretch and enlarge (dilate) much more than normal, to cope with the excessive amount of stools.
A very large stool may develop and get stuck (impacted) in an enlarged rectum.
If the rectum remains enlarged then the normal sensation of needing the toilet is reduced. The power to pass out a large stool is also reduced (the rectum becomes 'floppy').
More stools build up in the colon behind the impacted stool in the rectum.
The lowest part of an impacted stool lies just above the back passage (anus). Some of this stool liquefies (becomes runny) and leaks out of the anus. This soils the child's pants or bedclothes. Also, some softer, more liquid stools from higher up the colon may bypass around the impacted hard stool. This also leaks out and soils the pants or bedclothes and can be mistaken for diarrhoea. The child has no control of this leaking and soiling.
When a stool is eventually passed, because the rectum is distended and weakened, it simply fills up fairly quickly again with more hard stool from the backlog behind.
What is the treatment of idiopathic constipation?
Laxatives
Idiopathic constipation that has lasted for more than a few days is usually treated with laxatives. Your doctor will advise on the type and strength needed. This may depend on factors such as the age of the child, severity of the constipation and the response to the treatment. Laxatives for children commonly come either as sachets or a powder that is made up into a drink, or as liquid/syrup. The laxatives used for children are broadly divided into two types.
Macrogols (also called polyethylene glycols) are a type of laxative that pulls fluid into the bowel, keeping the stools soft. They are also known as osmotic laxatives. For example, Movicol® Paediatric Plain is one brand that is commonly used first. This is mixed into water to make a drink to which cordial, such as blackcurrant squash, can be added to make it taste nicer. Lactulose is another type of osmotic laxative.
Stimulant laxatives. These encourage (stimulate) the bowel to pass the stools out. There are several different types of stimulant laxative. Sodium picosulfate, bisacodyl, senna and docusate sodium are all examples. A stimulant laxative tends to be added in addition to a macrogol if the macrogol is not sufficient on its own.
Laxatives are normally continued for several weeks after the constipation has eased and a regular bowel habit has been established. This is called maintenance treatment. So, in total, the duration of treatment may be for several months. Do not stop the laxatives prescribed abruptly. Stopping laxatives abruptly might cause the constipation to quickly recur. Your doctor will normally advise a gradual reduction in the dose over a period of time depending on how the stools have become in their consistency and frequency. Some children may even require treatment with laxatives for several years.
Treatment of impaction - if needed
Similar treatments are used for the the treatments listed above. The main difference is that higher doses of laxatives are needed initially to clear the large amount of faeces blocking the last part of the bowel (the rectum). Secondly, laxatives are also usually needed for much longer, as maintenance treatment. The aim is to prevent a build-up of hard stools recurring again, which will prevent impaction returning.
As a result of maintenance treatment:
The enlarged rectum can gradually get back to a normal size and function properly again.
Constipation is then unlikely to recur.
If laxatives are stopped too soon, a large stool is likely to recur again in the weakened 'floppy' rectum which has not had time to get back to a normal size and strength.
Treatment to clear impacted stools from the rectum can be a difficult time for you and your child. It is likely that your child will actually have a few more tummy pains than before, and that there will be more soiled pants. It is important to persevere, as these problems are only temporary. Clearing the impacted stools is an essential part of treatment.
In rare instances, where treatment of impacted stools has failed, a child may be treated in hospital. In hospital, stronger medicines to empty the bowel, called enemas, can be given via the rectum. For very hard to treat cases, a child can have a general anaesthetic and the bowel can be cleared out manually by a surgeon.
Diet
Dietary measures should not be used on their own to treat idiopathic constipation, as it will be unlikely to solve the problem. However, it is still important to get a child into a habit of eating a good balanced diet. This is to include plenty of drinks (mainly water) and foods with fibre. This will help to prevent a recurrence of constipation once it has cleared.
How can constipation in children be prevented?
Eating foods with plenty of fibre and drinking plenty makes poo (faeces, stools or motions) that is bulky, but soft and easy to pass out. Getting plenty of exercise is also thought to help.
Food and fibre
This advice applies to babies who are weaned, and children. Foods which are high in fibre are: fruit, vegetables, cereals, wholemeal bread. A change to a high-fibre diet is often 'easier said then done', as many children are fussy eaters. However, any change is better than none. Listed below are some ideas to try to increase your child's fibre intake:
A meal of jacket potatoes with baked beans, or vegetable soup with bread.
Dried (or semi-dried) apricots or raisins for snacks.
Porridge or other high-fibre cereals (such as Weetabix®, Shredded Wheat® or All Bran®) for breakfast.
Offering fruit with every meal - perhaps cut up into little chunks to make it look more appealing.
Perhaps do not allow sweets or desserts until your child has eaten a piece of fruit.
Another tip for when children are reluctant to eat high-fibre foods is to add powdered bran to yoghurt. The yoghurt will feel grainy, but powdered bran is tasteless.
Drink
If a bottle-fed baby has a tendency to become constipated, you can try offering water between feeds. (Never dilute infant formula (milk) that is given to bottle-fed babies.) Although it is unusual for a breast-fed baby to become constipated, you can also offer water between feeds. Older, weaned babies can be given diluted fruit juice (preferably without added sugar). Pureed fruit and vegetables are the usual starting points for weaning, after baby rice, and these are good for preventing constipation.
Encourage children to drink plenty. However, some children get into the habit of only drinking squash, fizzy drinks or milk to quench their thirst. These may fill them up, and make them less likely to eat proper meals with food that contains plenty of fibre. Try to limit these kinds of drinks. Give water as the main drink. However, fruit juices that contain fructose or sorbitol have a laxative action (such as prune, pear, or apple juice). These may be useful from time to time if the stools become harder than usual and you suspect constipation may be developing.
Some other tips which may help
Try to get children into a regular toilet habit. After breakfast, before school or nursery, is often best. Try to allow plenty of time so they don't feel rushed.
Some kind of reward system is sometimes useful in younger children prone to holding on to stools. You could give a small treat, or use stickers or star charts to reinforce the message.
Praise your child for passing a stool in the potty or toilet, but do not punish accidents. It is easy to become frustrated with soiled pants or a child who refuses to pass a stool.
Try to keep calm and not make a fuss over the toilet issue. If your child can see that you are stressed or upset, they will pick up on this feeling, and the toileting issue can become even more of a fraught battle. The aim is to be 'matter of fact' and relaxed about it.
Your child's bowels - what is normal?
Parents often get very worried about their child's bowel habit. This anxiety can start when the child is a baby, with concern over the number of dirty nappies. The main thing to realise is that every child is different. Normal can vary quite a bit. It is a change in what is normal for your child, that suggests a problem.
Babies will open their bowels anything from several times per day, to once every few days. The frequency of bowel movements is not very important. What is important is that the poo (faeces, stools or motions) is soft and easily passed.
Breast-fed babies tend to pass runnier, mustard yellow-coloured stools. This is because breast milk is better digested than infant formula (bottle feeds). Newborn breast-fed babies may open their bowels with every feed. However, it is also normal for a breast-fed baby to go up to a week without a bowel movement.
Bottle-fed babies often need to open their bowels daily, as the stools are bulkier. Bottle-fed baby stools smell worse (more like an adult's).
It is not uncommon for your baby's stools to vary in colour and consistency from day to day. Any prolonged change to harder, less frequent stools might mean constipation.
As babies are weaned to solid foods, their stools will change in colour and smell. The frequency may again change. Generally, the stools become thicker, darker and a lot more smelly. You will notice that your baby's stools will alter depending upon what you have fed him or her. Some high-fibre foods, such as raisins, may even pass through your baby's bowels virtually unchanged, appearing in the nappy at the next change.
As your baby grows up, into a toddler and then a young child, you may see further changes in their stool frequency and consistency, often dependent on what they are eating.
Your child's bowels - what is abnormal?
As you can see, there is great variation in a child's bowel habit, dependent on their age and what they are fed. As already mentioned, it is a change in what is normal for your child, that suggests a problem. Anything from three times a day to once every other day is common and normal. Less often than every other day means that constipation is likely. However, it can still be normal if the stools are soft and well formed, and passed easily.
It may be normal for your baby to go a bit red in the face when straining to pass a stool. Constipation is more of a problem than this. Breast-fed babies seldom get constipated, as breast milk contains exactly the right balance of nutrients to keep the stools soft and easily passed.
Diarrhoea usually means very runny stools, often passed more frequently than normal. Breast-fed babies get diarrhoea less frequently than other babies, as breast milk has a protective effect against the germs that can cause diarrhoea.
What is constipation?
Constipation in children or babies can mean any, or all, of the following:
Difficulty or straining when passing stools.
Pain when passing stools, sometimes with a tiny amount of blood in the nappy or on the toilet paper, due to a small tear in the skin of the back passage (anus).
Passing stools less often than normal. Generally, this is less than three complete (proper) stools per week.
Stools that are hard, and perhaps very large, or pellet-like and small, like rabbit droppings.
Other symptoms of constipation
As well as less frequent, hard (and perhaps painful) stools, constipation can cause:
Tummy ache (abdominal pain).
Poor appetite.
General malaise (feeling 'off colour').
Behavioural changes, such as being more irritable or unhappy.
Fidgeting, restlessness and other signs that the child needs to go to the toilet.
Feeling sick (nausea).
Severe constipation can cause impaction (where a very large stool is stuck in the rectum). This can cause further symptoms. In particular, this can cause a child to soil their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea. Impaction is discussed in detail later.
Types of constipation in children and babies
Idiopathic constipation. This is common. The word idiopathic means of unknown cause. Various factors may be involved (discussed later), but many children become constipated for no known reason.
Short bouts of constipation. It is common for children and babies to have a bout of mild constipation for a day or so. This may settle quickly, often without the need for medical treatment.
Long-term constipation. In about 1 in 3 children who become constipated, the problem becomes more long-term (persistent). This is also called chronic idiopathic constipation.
Constipation due to an underlying disease or condition. This is uncommon. The constipation is said to be secondary to this other problem. Some examples of conditions and problems that can cause constipation are:
Some neurological conditions.
An underactive thyroid gland (hypothyroidism).
Cystic fibrosis.
Rare diseases with abnormal development of the bowel, such as Hirschsprung's disease.
As a side-effect of certain medications that a child has to take for another condition.
Treatment may involve treating the underlying condition (if that is possible) in addition to tackling the constipation. Worrying symptoms or signs that may indicate a secondary cause include the following. These should be mentioned to your GP. It is also possible that some of these symptoms could mean your child is more seriously unwell:
Being sick (vomiting).
Weight loss or failure to gain weight (thrive).
A swollen, stretched tummy.
Severe pain.
A baby that does not pass its first stool (called meconium) within the first 48 hours of life.
Abnormalities of the back passage (anus) - for example, if it is closed over.
Nervous system (neurological) problems such as weak or paralysed legs.
Sores or ulcers near the anus.
Excessive thirst.
Urinary symptoms - such as passing huge volumes of urine, urine that is very dark or painful urination with smelly urine.
Very pale-coloured stools (especially if the urine is very dark too).
The rest of this leaflet is about idiopathic constipation.
Does my child need any tests?
Tests are not normally needed to diagnose idiopathic constipation. Your GP is likely to ask various questions and do a general examination to rule out secondary causes of constipation. By examining your child's tummy (abdomen), a GP can tell if there are lots of stools in the bowel. This can give an indication if blockage (impaction - discussed later) has developed. (If an underlying cause of constipation is suspected, your GP will refer your child to a children's doctor (a paediatrician) and further tests may be done.)
What causes idiopathic constipation?
Idiopathic means that there is no disease or known cause for the constipation. However, it is thought that various factors may contribute to constipation developing, or make it worse. These include diet, stool holding and emotional factors.
Diet
Dietary factors that may play a part in constipation are:
Not eating enough foods with fibre (the roughage part of the food that is not digested and stays in the gut).
Not having enough to drink.
Stools tend to become harder, drier, and more difficult to pass if there is little fibre and fluid in the gut.
Stool holding
This means the child has the feeling of needing the toilet, but resists it. The child holds on to the stool, trying to ignore the desire to empty the bowels. This is quite common. You may see your child crossing their legs, sitting on the back of the heels, or doing similar things to help resist the feeling of needing the toilet. Your child may clench his or her buttocks to try to stop the stool from coming out, and may seem quite fidgety. You may notice smudges of stool on your child's pants, often when they are unable to hold on any longer. The longer the child holds on, the bigger the stool gets. Eventually the child has to go, but the large stool is more difficult to pass, and often more painful. This may lead to a bit of a vicious cycle where the child is even more reluctant to open his or her bowels the next time. There are a number of reasons why children may hold on to stools:
A previous stool that they passed may have been a struggle or painful. So, they try to put off doing it again.
Their back passage (anus) may be sore or have a crack (anal fissure) from passing a previous large stool. It is then painful to pass further stools. So, the child may resist the urge to pass a stool.
They may have a dislike of unfamiliar or smelly toilets, such as at school or on holiday. The child may want to put things off until they get home.
Emotional problems
Constipation problems may be made worse with upset due to change in surroundings or routine. Common examples are moving house and starting nursery. Potty training may be a factor if a child becomes scared of using the potty. Fears and phobias are usually the underlying reasons for these problems.
What is idiopathic constipation with impaction?
Impaction means that the bowel is, in effect, blocked by a large amount of hard stool. Idiopathic constipation with impaction most commonly develops in children between the ages of 2 and 4 years, but older or younger children can be affected. Symptoms and features include:
Recurrent episodes when the child is uncomfortable or distressed trying to pass a stool.
The child soils their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea.
The child may also become irritable, not eat much, feel sick, have tummy pains from time to time, and may be generally out of sorts.
A doctor can often feel a backlog of hard, lumpy stools when he or she examines the child's tummy (abdomen).
The diagram below shows how a child may develop impaction, and the symptoms this may cause.
Normally, stools build up in the lowest part of the bowel.
When stools accumulate, they start to pass into the last part of the bowel (the rectum), which stretches. This sends nerve messages to the brain, telling you that you need to empty your bowels.
If the stool is not passed out then more stools from higher up also reach the rectum.
Eventually, large hard stools may build up in the rectum.
The rectum may then stretch and enlarge (dilate) much more than normal, to cope with the excessive amount of stools.
A very large stool may develop and get stuck (impacted) in an enlarged rectum.
If the rectum remains enlarged then the normal sensation of needing the toilet is reduced. The power to pass out a large stool is also reduced (the rectum becomes 'floppy').
More stools build up in the colon behind the impacted stool in the rectum.
The lowest part of an impacted stool lies just above the back passage (anus). Some of this stool liquefies (becomes runny) and leaks out of the anus. This soils the child's pants or bedclothes. Also, some softer, more liquid stools from higher up the colon may bypass around the impacted hard stool. This also leaks out and soils the pants or bedclothes and can be mistaken for diarrhoea. The child has no control of this leaking and soiling.
When a stool is eventually passed, because the rectum is distended and weakened, it simply fills up fairly quickly again with more hard stool from the backlog behind.
What is the treatment of idiopathic constipation?
Laxatives
Idiopathic constipation that has lasted for more than a few days is usually treated with laxatives. Your doctor will advise on the type and strength needed. This may depend on factors such as the age of the child, severity of the constipation and the response to the treatment. Laxatives for children commonly come either as sachets or a powder that is made up into a drink, or as liquid/syrup. The laxatives used for children are broadly divided into two types.
Macrogols (also called polyethylene glycols) are a type of laxative that pulls fluid into the bowel, keeping the stools soft. They are also known as osmotic laxatives. For example, Movicol® Paediatric Plain is one brand that is commonly used first. This is mixed into water to make a drink to which cordial, such as blackcurrant squash, can be added to make it taste nicer. Lactulose is another type of osmotic laxative.
Stimulant laxatives. These encourage (stimulate) the bowel to pass the stools out. There are several different types of stimulant laxative. Sodium picosulfate, bisacodyl, senna and docusate sodium are all examples. A stimulant laxative tends to be added in addition to a macrogol if the macrogol is not sufficient on its own.
Laxatives are normally continued for several weeks after the constipation has eased and a regular bowel habit has been established. This is called maintenance treatment. So, in total, the duration of treatment may be for several months. Do not stop the laxatives prescribed abruptly. Stopping laxatives abruptly might cause the constipation to quickly recur. Your doctor will normally advise a gradual reduction in the dose over a period of time depending on how the stools have become in their consistency and frequency. Some children may even require treatment with laxatives for several years.
Treatment of impaction - if needed
Similar treatments are used for the the treatments listed above. The main difference is that higher doses of laxatives are needed initially to clear the large amount of faeces blocking the last part of the bowel (the rectum). Secondly, laxatives are also usually needed for much longer, as maintenance treatment. The aim is to prevent a build-up of hard stools recurring again, which will prevent impaction returning.
As a result of maintenance treatment:
The enlarged rectum can gradually get back to a normal size and function properly again.
Constipation is then unlikely to recur.
If laxatives are stopped too soon, a large stool is likely to recur again in the weakened 'floppy' rectum which has not had time to get back to a normal size and strength.
Treatment to clear impacted stools from the rectum can be a difficult time for you and your child. It is likely that your child will actually have a few more tummy pains than before, and that there will be more soiled pants. It is important to persevere, as these problems are only temporary. Clearing the impacted stools is an essential part of treatment.
In rare instances, where treatment of impacted stools has failed, a child may be treated in hospital. In hospital, stronger medicines to empty the bowel, called enemas, can be given via the rectum. For very hard to treat cases, a child can have a general anaesthetic and the bowel can be cleared out manually by a surgeon.
Diet
Dietary measures should not be used on their own to treat idiopathic constipation, as it will be unlikely to solve the problem. However, it is still important to get a child into a habit of eating a good balanced diet. This is to include plenty of drinks (mainly water) and foods with fibre. This will help to prevent a recurrence of constipation once it has cleared.
How can constipation in children be prevented?
Eating foods with plenty of fibre and drinking plenty makes poo (faeces, stools or motions) that is bulky, but soft and easy to pass out. Getting plenty of exercise is also thought to help.
Food and fibre
This advice applies to babies who are weaned, and children. Foods which are high in fibre are: fruit, vegetables, cereals, wholemeal bread. A change to a high-fibre diet is often 'easier said then done', as many children are fussy eaters. However, any change is better than none. Listed below are some ideas to try to increase your child's fibre intake:
A meal of jacket potatoes with baked beans, or vegetable soup with bread.
Dried (or semi-dried) apricots or raisins for snacks.
Porridge or other high-fibre cereals (such as Weetabix®, Shredded Wheat® or All Bran®) for breakfast.
Offering fruit with every meal - perhaps cut up into little chunks to make it look more appealing.
Perhaps do not allow sweets or desserts until your child has eaten a piece of fruit.
Another tip for when children are reluctant to eat high-fibre foods is to add powdered bran to yoghurt. The yoghurt will feel grainy, but powdered bran is tasteless.
Drink
If a bottle-fed baby has a tendency to become constipated, you can try offering water between feeds. (Never dilute infant formula (milk) that is given to bottle-fed babies.) Although it is unusual for a breast-fed baby to become constipated, you can also offer water between feeds. Older, weaned babies can be given diluted fruit juice (preferably without added sugar). Pureed fruit and vegetables are the usual starting points for weaning, after baby rice, and these are good for preventing constipation.
Encourage children to drink plenty. However, some children get into the habit of only drinking squash, fizzy drinks or milk to quench their thirst. These may fill them up, and make them less likely to eat proper meals with food that contains plenty of fibre. Try to limit these kinds of drinks. Give water as the main drink. However, fruit juices that contain fructose or sorbitol have a laxative action (such as prune, pear, or apple juice). These may be useful from time to time if the stools become harder than usual and you suspect constipation may be developing.
Some other tips which may help
Try to get children into a regular toilet habit. After breakfast, before school or nursery, is often best. Try to allow plenty of time so they don't feel rushed.
Some kind of reward system is sometimes useful in younger children prone to holding on to stools. You could give a small treat, or use stickers or star charts to reinforce the message.
Praise your child for passing a stool in the potty or toilet, but do not punish accidents. It is easy to become frustrated with soiled pants or a child who refuses to pass a stool.
Try to keep calm and not make a fuss over the toilet issue. If your child can see that you are stressed or upset, they will pick up on this feeling, and the toileting issue can become even more of a fraught battle. The aim is to be 'matter of fact' and relaxed about it.
Wednesday, February 20, 2013
Bogus nutritional claims - beware from nutritional advertisements
Leading health products are in the dock of falsely exaggerating nutrition value of their products
You are being led up the garden path by manufacturers of food and health products making tall claims in advertisements.
The Food Safety and Standards Authority of India (FSSAI) - which put many products under its scanner over the misleading claims - has initiated proceedings in 38 cases involving leading brands.
The food regulator, which has received complaints against the products, has begun prosecution proceedings in 19 cases under the Food Safety and Standards (FSS) Act.
Show-cause notices have been issued in the other 19 cases. The advertisements of the products, which are popular with most Indian households, promise quick results from slimming to healthy heart and faster growth for children.
The food regulator, which has presented a report to Parliament on the action taken in these cases, found that the companies manufacturing the food and health products not only made misleading claims in the advertisements but also carried similar pictures on the packaging.
For instance, Complan is currently facing prosecution for claiming one can "grow two times faster". Complan Memory is in trouble over claims of boosting memory.
Boost and Horlicks, popular nutrition food for children made by Glaxo Smithkline, claimed they were better for stamina building than regular chocolate drinks and made children taller, stronger and sharper.
The FSSAI said these claims were "misleading, and no study has been submitted" to back the claims.
On Kellogg's Extra Muesli, the food regulator said the "label showed a number of fruits thus making a misleading claim that product contained too many fruits".
Others products under the food regulator's scanner are Emami Soyabean Oil, Saffola, Nutri Charge Men, Engine mustard oil, Kellogg's Special K, Britannia NutriChoice biscuits, Today Premium Tea, PediaSure drinks, Real Active Fibre +, Nutrilite, Kissan Cream Spread, Rajdhani Besan and Britannia Vita Marie.
These were found to have promised higher health benefits, higher nutritional value, or faster benefits like losing weight or ensuring growth.
The report presented to Parliament by FSSAI showed it had rejected some of the replies to the notices given by the companies saying they "cannot be accepted".
No comments
When contacted by Mail Today, officials from various companies like Kellogg's, Glaxo SmithKline that manufactures Horlicks and Nestle which makes Maggi declined to comment immediately.
However, the officials were aware of the show-cause notices issued to their firms by FSSAI. Chandra Bhushan, deputy director of the Centre for Science and Environment(CSE), said, "Only notices have issued but no action has been taken. Still, it's good that notices have been issued."
Click here to Enlarge
"Misbranding is a huge problem in the country. The companies target especially children and the health conscious, which is a very emotive issue."
He said the Advertising Standards Council of India is ineffective in putting curbs on such misleading ads. He added that under the current provisions of the FSS Act, a fine of `10 lakh is very small.
He suggested that penalty should be proportionate to the turnover. "Major reforms are needed in the sector to save people," Bhushan said.
Neelanjana Singh, consultant nutritionist at PSRI Hospital said, "Our children cannot just become taller with that special drink. Height, for example, is largely dependent on genes and nutrition."
"Just a drink might add to the nutrition but cannot solely be given credit for it. If we are to believe the manufacturing companies' claims, all health woes will just disappear."
Deceptive ads
Singh described the ads as deceptive. She said some drinks boast of being magic potions which can strengthen a child's immune system, protect them from cold and cough but have almost no medicinal content.
"There is no scientific evidence to back their claims," she said. For special health drinks, dieticians said that their nutrition value, in fact, is low.
"In almost all these health drinks in the market, you would find from their labels that less than 6-7 per cent of their total content actually has proteins and vitamins vital for growth."
"The rest of the drink has processed ingredients, with 30 per cent sugar and 30 per cent carbs. The different flavours too are processed, rendering them in certain cases, unhealthy," said Shilpa Thakur, chief dietician at the Asian Institute of Medical Sciences.
Said Ishi Khosla, clinical nutritionist and founder, Whole Foods on breakfast cereals, "Breakfast cereals which are said to be storehouses of energy, are marketed as fat free but they are high in sugar content."
"The advertisers are simply riding high on the health bandwagon which everyone seems to have joined."
In March this year, CSE had lab tested many of the popular brands and found that most of them had higher quantity of trans fats, sugar and salt than claimed in the labels.
The misleading advertisements come under the purview of the FSSAI and the Information and Broadcasting ministry. Consumers often write to these bodies against products making big claims.
The Information and Broadcasting ministry, on its part, claimed that it had issued an advisory to all channels in May 2010 warning against advertising products promising special and miraculous cure.
Khosla said that a "health fear" had gripped people. "These companies are simply playing on the fear factor by making fat claims.
The competition is too stiff and that has led to the spurt in the health products and their claims are getting bigger and bigger. Consumers should read the fine print carefully before falling for them."
Tuesday, February 12, 2013
Chronic Urticaria Review
Urticaria is a common condition, in which the majority of cases are non-allergenic. A focused clinical history and physical examination are the most useful tools when diagnosing and treating urticaria. Specific triggers are often not found, therefore extensive diagnostic testing is not recommended, unless there is strong evidence to suspect a specific trigger. In some cases, urticaria may be a symptom of an underlying systemic disease and it is important to be aware of this possibility and to refer for further investigation when necessary.
Classification and aetiology of urticaria
Urticaria is the term used to describe a group of skin conditions, characterised by the presence of wheals. Approximately one in five people experience urticaria (commonly referred to as hives) at some stage in their life.1,2 In many cases, a specific trigger for the urticaria is not found. In rare cases, urticaria may be a sign of systemic disease, such as an autoimmune condition.
The two main classifications of urticaria are:
Ordinary (spontaneous) urticaria – which can be acute or chronic
Physical urticaria
Acute urticaria describes "one-off" outbreaks and recurrent episodes occurring over a period of less than six weeks. It is the most common type of urticaria, and is more frequently seen in children and young adults.1,3 It is estimated that 20 – 30% of cases of acute urticaria in infants and young children develop into chronic urticaria.4 Approximately 50% of cases of acute urticaria are idiopathic, i.e. a specific trigger is not identified.3
Chronic urticaria describes episodes of urticaria which occur over a period longer than six weeks. In rare cases urticaria may persist for a lifetime, but this is more common in cases of physical urticaria .5 Approximately 30% of patients presenting in primary care with urticaria will have chronic urticaria.6 Chronic urticaria occurs more frequently in adults, and in women (approximately 60% of cases).1 It is estimated that in 40% of people with chronic urticaria, there is evidence of an autoimmune process, and in 20% there is evidence of a physical stimulus,1 although a specific cause is often not found.
Physical urticaria occurs in a localised area after contact with a physical stimulus. Individual episodes usually resolve within a two hour period, but physical urticaria often persists as a chronic, recurring condition.3 Dermatographism (skin writing) is the most common form of physical urticaria, triggered by firm stroking or scratching of the skin, or contact with clothes or other objects (Figure 1).3
Other types of physical urticaria include;
Contact urticaria – absorption of substances through the skin or mucous membranes
Cholinergic urticaria – sweating, e.g. after exercise or exposure to heat
Delayed pressure urticaria – sustained pressure to a site on the body, e.g. on the buttocks after sitting
Cold urticaria – most frequently caused by swimming in cold water or exposure to cold wind (Figure 2)
Solar urticaria
Vibratory urticaria
Figure 1: Dermatographism
Images provided by DermnetNZ Figure 2: Cold urticaria
Most cases of urticaria are non-allergenic
Most cases of urticaria are not caused by allergy but are the result of histamine being released by direct mast cell degranulation (i.e non-IgE mediated).
Examples of causes of non-allergenic urticaria include:2
Infection – bacterial (e.g. Helicobacter pylori, Mycoplasma pneumoniae), viral (e.g. infectious mononucleosis, viral hepatitis), parasitic (e.g. Giardia) or fungal (e.g. Candida)
Medicines – especially opiates, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs)
Non-allergenic contact with topical compounds, food preservatives, raw meat or vegetables
Non-allergenic food reactions to compounds such as alcohol, salicylates in fruit or from bacterial decomposition (food poisoning)
Hypersensitivity to physical stimuli such as scratching, friction from clothing or other objects, light, heat, cold, water or vibration
Autoimmune conditions such as systemic lupus erythematosus and autoimmune thyroid disease
Allergy-induced urticaria
Allergy induced urticaria is most common in people with a history of atopy.
Examples of causes of allergenic urticaria include:2
Medicines, e.g. antibiotics
Food allergy, e.g. fish, eggs or nuts
Insect stings, e.g. wasp, bee
Contact allergens, e.g. latex or cosmetics
Clinical history and examination
Clinical history and physical examination are usually sufficient to diagnose urticaria. A specific cause is identified in approximately one-half of patients with acute urticaria and one-quarter of patients with chronic urticaria.3,7
Clinical history
The clinical history should cover:
Frequency, size, distribution and duration of the lesions – to determine type of urticaria
Recent consumption of new or unusual food or medicines, recent infections, or participation in or exposure to new activities, locations or products or chemicals – to determine potential triggers
Occupational exposure to chemicals or inhalants – to determine potential long-term triggers
History of similar episodes and response to treatment
Personal and family history of atopy – more likely to be allergy-induced urticaria
Physical examination: clinical features of urticaria
Figure 3: Classical whealing
Figure 4: Annular pattern
Figure 5: Giant urticaria
Images provided by DermnetNZ
An episode of urticaria is identified by highly pruritic, well-defined, pink-to-red wheals, often with a pale centre (Figure 3), which usually last no more than 48 hours and leave no remaining marks. The lesions may occur anywhere on the skin and can range in size, from a few millimetres to centimetres, and vary in shape, forming round, oval, annular (ring) (Figure 4), serpiginous (wavy), gyrate (circular, coiled) or targetoid (target pattern) plaques. The lesions may also merge to form large geographic or giant patches (Figure 5). The surface skin remains smooth. The presentation of urticaria is similar in both children and adults.
Approximately 40% of people with urticaria also have signs of angioedema.1 Angioedema involves the deeper epidermis and subcutaneous tissues and most frequently affects the eyes, mouth, throat, tongue, hands and feet. Angioedema without urticaria is rare and can be life-threatening if the larynx is involved. Further discussion of this condition is outside the scope of this article.
Further examination should be guided by the clinical history. Dermatographism can be tested for by stroking the skin firmly and looking for linear wheals occurring within a five minute period. The application for several minutes of an ice cube, heat, pressure or water may rule out other forms of physical urticaria.
In some cases, examination may be necessary for underlying conditions that may precipitate urticaria, such as:
Bacterial or fungal infections of the skin
Autoimmune thyroid disease – may be indicated by an enlarged thyroid
Connective tissue diseases – may be indicated by joint swelling or tenderness or oral ulceration, e.g. rheumatoid arthritis, systemic lupus erythematosus
Liver disease/dysfunction – may be indicated by tenderness on palpation of the liver or jaundice, e.g. cholestasis can cause pruritus and acute urticaria can be an early sign of hepatitis A, B and rarely C8
Differential diagnosis
There are a large number of conditions (some of them rare) which may cause symptoms similar to urticaria. The transient and pruritic nature of lesions is one of the most distinctive aspects of urticaria, but pruritus is sometimes absent. Angioedema is also more likely to be associated with urticaria than other skin conditions.
If the signs and symptoms are not typical of urticaria, other diagnoses that may be considered include:
Atopic dermatitis – usually highly pruritic, but can be distinguished from urticaria by the lack of transitory wheals, excessively dry skin and other skin surface abnormalities, strongly associated with personal or family history of atopy
Contact dermatitis – can be distinguished from urticaria by a lack of transitory wheals and the presence of skin surface changes such as blisters, dryness and peeling
Fixed drug eruptions – tender, well defined, round or oval patches, often with central blistering that generally occur in the same place on the body each time a specific medicine is taken
Erythema multiforme – an acute, and at times recurring, hypersensitivity to a variety of causes including infections and medicines. Lesions are usually present on the face and distal limbs and can last for up to seven days.
Bullous pemphigoid – a chronic, autoimmune condition, which usually affects elderly people. Characterised by erosions and tense bullae filled with clear, cloudy or blood-stained fluid, most frequently occurring in body folds.
Urticarial vasculitis – characterised by wheals that resemble urticaria, but last longer than 48 hours and often leave bruising and areas of increased pigmentation as they resolve
Papular urticaria – urticated pruritic papules at the site of insect bites, common in young children and in people who have travelled.
Laboratory investigation of urticaria
Laboratory testing is not indicated for patients with acute urticaria as the diagnosis is usually clinical.
In patients with chronic urticaria, testing does not usually help to establish a cause, direct management or improve patient outcomes.9 In a study of 356 patients with urticaria referred for allergy and immunology evaluation, only one patient benefited from a change in management due to testing and only 319 (17%) of the 1872 tests ordered had abnormal findings.10
Laboratory testing may be useful in selected patients with chronic urticaria, e.g. if an underlying condition is suspected, they have failed to respond to treatment, or if the condition is severe.9 The choice of investigations should be guided by positive findings from the clinical history and physical examination. Discussion with a dermatologist may also be helpful.
The following investigations may be appropriate for specific clinical circumstances:
Skin prick testing may be considered when an allergic cause for the urticaria is suspected and confirmation would be useful for management, e.g. if avoidance measures are being considered. Skin prick testing should not be performed routinely. Skin prick testing may not be reliable in older adults and children aged under two years should be referred to an allergy clinic for testing as the results may be difficult to interpret. Skin prick testing in pregnant women should only be requested if the benefits outweigh the risks, as in rare cases it can cause uterine contractions.11
Serum allergen-specific IgE testing is second-line to skin prick testing when skin prick testing is unsuitable or unavailable.
For further information see: "Appropriate use of allergy testing in primary care", Best Tests (Dec, 2011)
Full blood count may indicate an allergy or an intestinal infection if the eosinophil count is elevated. Neutropenia may suggest an autoimmune or viral cause, while neutrophilia may be caused by a bacterial infection. Acute viral infections, e.g. Epstein-Barr virus, or autoimmune thyroiditis may cause a high lymphocyte count.
Thyroid antibody testing may be useful following discussion with an appropriate specialist, if a thyroid autoimmune disorder is suspected. Chronic autoimmune urticaria is associated with antithyroid antibodies in approximately one-quarter of cases.3
Skin biopsy (3 mm punch biopsy) is only rarely required, if urticarial vasculitus is suspected or when the diagnosis is uncertain. Atypical features of urticaria include pain or burning rather than pruritis, complete non-response to anti-histamines, wheals persisting for longer than 48 hours, or not fully resolving, with remaining hyperpigmentation.
Best Practice tip: Before contacting a dermatologist, take anatomic views and close-up digital images of the patient's skin lesions. Emailing good quality clinical images may assist the discussion, particularly if the patient's clinical signs are intermittent.
Treatment for urticaria
Acute urticaria generally resolves over a short period of time, however, chronic urticaria can persist for months or even years (particularly physical urticaria). This can be frustrating for both patient and doctor, especially when there is no known cause.
In a study of 220 patients with chronic idiopathic urticaria, it was found that after one year:6
47% were symptom-free
60% with ordinary urticaria and angioedema were symptom free
39% with ordinary urticaria only were symptom free
16% with physical urticaria were symptom free
Management is focused on avoiding triggers where known, and using medicines for symptom relief.
Avoidance strategies
When the clinical history does not reveal an obvious cause for the urticaria, an avoidance strategy for potential triggers may be considered.
Patients can be advised to stop any non-essential medicines, herbal supplements or topical preparations. In particular, aspirin, codeine and non-steroidal anti-inflammatory drugs (NSAIDs) may contribute to wheal formation, even when they are not the primary cause of the eruption. If symptoms resolve (or do not recur), medicines/products can be reintroduced sequentially, if necessary, and the patient should report any return of symptoms.
Dietary investigations rarely identify a specific trigger for chronic urticaria, and are not necessary in cases where symptoms can be easily controlled with oral antihistamines. However, if the patient wishes to, a food diary may be used to record and eliminate suspected triggers. Particularly motivated people may try a narrow diet of rice and a single source of protein for two weeks, while discontinuing all antihistamines. Foods can then be slowly reintroduced and reactions noted in the food diary.1
Pharmacological treatment
Introduction of medicines for the treatment of urticaria should be considered in the following order:
Commence non-sedating oral antihistamines
Add conventional sedating oral antihistamines and/or H2 receptor antagonists
Add tricyclic antidepressants
Add oral corticosteroids - only for patients with severe acute urticaria
Non-sedating oral antihistamines are the first-line pharmacological treatment for both acute and chronic urticaria due to their effectiveness and relative lack of anticholinergic and central nervous system effects. Although referred to as "non-sedating", these medicines may still cause sedation at usual doses in some patients. In New Zealand cetirizine and loratadine are fully-funded (see Table 1 for recommended doses). Individual response to antihistamines may be variable, however, cetirizine is thought to be the quickest acting, therefore may be trialled first.2
Table 1: Recommended doses for fully-funded, non-sedating antihistamines available in New Zealand13,14,15
Antihistamine Adult dose Child dose (6 –12 years) Child dose (2 – 6 years)
Cetirizine 10 mg, once or twice daily* 10 mg, once daily or in divided doses 5 mg, once daily or in divided doses
Loratadine 10 mg, once or twice daily* > 30 kg: 10 mg, once daily
< 30 kg: 5 mg, once daily 5 mg, once daily
* Although the maximum dose in the New Zealand medicine datasheet is 10 mg, this medicine is often used (and required) in higher doses, without any reports of adverse effects, in order to successfully manage urticaria12,16
Oral antihistamines may be taken on an "as-required" basis, due to their rapid onset of action, but may be more effective when taken daily. The recommended maximum adult dose of cetirizine and loratadine is 10 mg per day, however, European guidelines recommend non-sedating antihistamines be prescribed at up to four times the standard dose (i.e. cetirizine or loratadine 40 mg daily) before second-line medicines are considered as adjunctive treatment.12
Sedating oral antihistamines are rarely used as a monotherapy for urticaria, but can be used in combination with non-sedating antihistamines. These medicines may be useful for patients with nocturnal symptoms that prevent sleep. Promethazine (fully funded) is a suitable choice and can be prescribed at the following doses:13,14
Adults; 25 – 75 mg, at night
Children aged five to ten years; 10 – 25 mg, at night
Children aged two to five years; 5 – 15 mg, at night
H2 receptor antagonists such as ranitidine or famotidine, when used in combination with antihistamines, may be of benefit to some people with chronic urticaria as 15% of histamine receptors in the skin are H2-type.3 These medicines are not recommended as monotherapy because their ability to reduce pruritus is limited and there is little clinical evidence of their effectiveness.
Tricyclic antidepressants have histamine receptor antagonist activity and may be especially useful in treating chronic urticaria, in combination with non-sedating antihistamines. Due to its sedating properties doxepin (30 – 50 mg) is an appropriate treatment for nocturnal symptoms. Amitriptyline (10 – 50 mg) may also be effective.
Oral corticosteroids may be added for people with severe acute urticaria. The recommended dose for adults is 20 – 40 mg daily, or for children 1 mg/kg daily, maximum 40 mg, tapering to the lowest effective dose over the course of two to five days.13 Corticosteroids are nearly always inappropriate in people with chronic urticaria as long-term use should be avoided.
N.B. Topical corticosteroids are not useful in the treatment of urticaria and may cause adverse effects with longer-term or higher-potency use, e.g. skin atrophy. Topical antihistamines are also not effective for treating urticaria and are not recommended due to the risk of sensitisation and resulting contact dermatitis.17
Cooling preparations containing 0.5 – 1% menthol in a cream or lotion base, e.g. cetomacrogol cream, may provide symptom relief. The use of cool damp cloths, reduction of night-time heating and tepid showers may also be useful.
Referral for specialist treatment may be considered if the diagnosis is uncertain or where symptoms are severe and poorly controlled. A number of further treatment options are available including immunosuppressants, e.g. cyclosporin, and leukotriene receptor agonists, e.g. montelukast. If a complex drug or food trigger is suspected then consider referral to an immunologist. Phototherapy using ultraviolet B radiation reduces the number of mast cells in the upper dermis,12 and may be effective in reducing symptoms in cases of physical urticaria that are resistant to antihistamines.18 Patients can be referred to a dermatologist for this treatment.
Best Practice tip: A standard treatment regimen for urticaria – begin with cetirizine, if symptoms are not controlled, add promethazine 25 mg at night and raniditine 300 mg during the day. This will settle symptoms for most people. If symptoms still persist, add in a tricyclic antidepressant.
Antihistamines during pregnancy
Ordinary urticaria is uncommon in pregnant women and little is known about the safety of antihistamines in women who are pregnant or breastfeeding. The majority of information that is available concerns the older, first-generation sedating antihistamines. Generally, all antihistamines should be avoided by women who are pregnant, especially during the first and third trimester.17 However, there have been no reports of major birth abnormalities in women who have used newer, non-sedating antihistamines during pregnancy.12 Loratadine (pregnancy category B1)19 may be considered for the treatment of urticaria in women who are pregnant when the benefits of treatment are thought to outweigh the risks.12 Sedating antihistamines may be considered in severe cases of urticaria occurring during pregnancy, if the patient has not responded to non-sedating antihistamines. However, these medicines should be avoided around the time of delivery to reduce the chance of causing sedation in the infant.
Classification and aetiology of urticaria
Urticaria is the term used to describe a group of skin conditions, characterised by the presence of wheals. Approximately one in five people experience urticaria (commonly referred to as hives) at some stage in their life.1,2 In many cases, a specific trigger for the urticaria is not found. In rare cases, urticaria may be a sign of systemic disease, such as an autoimmune condition.
The two main classifications of urticaria are:
Ordinary (spontaneous) urticaria – which can be acute or chronic
Physical urticaria
Acute urticaria describes "one-off" outbreaks and recurrent episodes occurring over a period of less than six weeks. It is the most common type of urticaria, and is more frequently seen in children and young adults.1,3 It is estimated that 20 – 30% of cases of acute urticaria in infants and young children develop into chronic urticaria.4 Approximately 50% of cases of acute urticaria are idiopathic, i.e. a specific trigger is not identified.3
Chronic urticaria describes episodes of urticaria which occur over a period longer than six weeks. In rare cases urticaria may persist for a lifetime, but this is more common in cases of physical urticaria .5 Approximately 30% of patients presenting in primary care with urticaria will have chronic urticaria.6 Chronic urticaria occurs more frequently in adults, and in women (approximately 60% of cases).1 It is estimated that in 40% of people with chronic urticaria, there is evidence of an autoimmune process, and in 20% there is evidence of a physical stimulus,1 although a specific cause is often not found.
Physical urticaria occurs in a localised area after contact with a physical stimulus. Individual episodes usually resolve within a two hour period, but physical urticaria often persists as a chronic, recurring condition.3 Dermatographism (skin writing) is the most common form of physical urticaria, triggered by firm stroking or scratching of the skin, or contact with clothes or other objects (Figure 1).3
Other types of physical urticaria include;
Contact urticaria – absorption of substances through the skin or mucous membranes
Cholinergic urticaria – sweating, e.g. after exercise or exposure to heat
Delayed pressure urticaria – sustained pressure to a site on the body, e.g. on the buttocks after sitting
Cold urticaria – most frequently caused by swimming in cold water or exposure to cold wind (Figure 2)
Solar urticaria
Vibratory urticaria
Figure 1: Dermatographism
Images provided by DermnetNZ Figure 2: Cold urticaria
Most cases of urticaria are non-allergenic
Most cases of urticaria are not caused by allergy but are the result of histamine being released by direct mast cell degranulation (i.e non-IgE mediated).
Examples of causes of non-allergenic urticaria include:2
Infection – bacterial (e.g. Helicobacter pylori, Mycoplasma pneumoniae), viral (e.g. infectious mononucleosis, viral hepatitis), parasitic (e.g. Giardia) or fungal (e.g. Candida)
Medicines – especially opiates, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs)
Non-allergenic contact with topical compounds, food preservatives, raw meat or vegetables
Non-allergenic food reactions to compounds such as alcohol, salicylates in fruit or from bacterial decomposition (food poisoning)
Hypersensitivity to physical stimuli such as scratching, friction from clothing or other objects, light, heat, cold, water or vibration
Autoimmune conditions such as systemic lupus erythematosus and autoimmune thyroid disease
Allergy-induced urticaria
Allergy induced urticaria is most common in people with a history of atopy.
Examples of causes of allergenic urticaria include:2
Medicines, e.g. antibiotics
Food allergy, e.g. fish, eggs or nuts
Insect stings, e.g. wasp, bee
Contact allergens, e.g. latex or cosmetics
Clinical history and examination
Clinical history and physical examination are usually sufficient to diagnose urticaria. A specific cause is identified in approximately one-half of patients with acute urticaria and one-quarter of patients with chronic urticaria.3,7
Clinical history
The clinical history should cover:
Frequency, size, distribution and duration of the lesions – to determine type of urticaria
Recent consumption of new or unusual food or medicines, recent infections, or participation in or exposure to new activities, locations or products or chemicals – to determine potential triggers
Occupational exposure to chemicals or inhalants – to determine potential long-term triggers
History of similar episodes and response to treatment
Personal and family history of atopy – more likely to be allergy-induced urticaria
Physical examination: clinical features of urticaria
Figure 3: Classical whealing
Figure 4: Annular pattern
Figure 5: Giant urticaria
Images provided by DermnetNZ
An episode of urticaria is identified by highly pruritic, well-defined, pink-to-red wheals, often with a pale centre (Figure 3), which usually last no more than 48 hours and leave no remaining marks. The lesions may occur anywhere on the skin and can range in size, from a few millimetres to centimetres, and vary in shape, forming round, oval, annular (ring) (Figure 4), serpiginous (wavy), gyrate (circular, coiled) or targetoid (target pattern) plaques. The lesions may also merge to form large geographic or giant patches (Figure 5). The surface skin remains smooth. The presentation of urticaria is similar in both children and adults.
Approximately 40% of people with urticaria also have signs of angioedema.1 Angioedema involves the deeper epidermis and subcutaneous tissues and most frequently affects the eyes, mouth, throat, tongue, hands and feet. Angioedema without urticaria is rare and can be life-threatening if the larynx is involved. Further discussion of this condition is outside the scope of this article.
Further examination should be guided by the clinical history. Dermatographism can be tested for by stroking the skin firmly and looking for linear wheals occurring within a five minute period. The application for several minutes of an ice cube, heat, pressure or water may rule out other forms of physical urticaria.
In some cases, examination may be necessary for underlying conditions that may precipitate urticaria, such as:
Bacterial or fungal infections of the skin
Autoimmune thyroid disease – may be indicated by an enlarged thyroid
Connective tissue diseases – may be indicated by joint swelling or tenderness or oral ulceration, e.g. rheumatoid arthritis, systemic lupus erythematosus
Liver disease/dysfunction – may be indicated by tenderness on palpation of the liver or jaundice, e.g. cholestasis can cause pruritus and acute urticaria can be an early sign of hepatitis A, B and rarely C8
Differential diagnosis
There are a large number of conditions (some of them rare) which may cause symptoms similar to urticaria. The transient and pruritic nature of lesions is one of the most distinctive aspects of urticaria, but pruritus is sometimes absent. Angioedema is also more likely to be associated with urticaria than other skin conditions.
If the signs and symptoms are not typical of urticaria, other diagnoses that may be considered include:
Atopic dermatitis – usually highly pruritic, but can be distinguished from urticaria by the lack of transitory wheals, excessively dry skin and other skin surface abnormalities, strongly associated with personal or family history of atopy
Contact dermatitis – can be distinguished from urticaria by a lack of transitory wheals and the presence of skin surface changes such as blisters, dryness and peeling
Fixed drug eruptions – tender, well defined, round or oval patches, often with central blistering that generally occur in the same place on the body each time a specific medicine is taken
Erythema multiforme – an acute, and at times recurring, hypersensitivity to a variety of causes including infections and medicines. Lesions are usually present on the face and distal limbs and can last for up to seven days.
Bullous pemphigoid – a chronic, autoimmune condition, which usually affects elderly people. Characterised by erosions and tense bullae filled with clear, cloudy or blood-stained fluid, most frequently occurring in body folds.
Urticarial vasculitis – characterised by wheals that resemble urticaria, but last longer than 48 hours and often leave bruising and areas of increased pigmentation as they resolve
Papular urticaria – urticated pruritic papules at the site of insect bites, common in young children and in people who have travelled.
Laboratory investigation of urticaria
Laboratory testing is not indicated for patients with acute urticaria as the diagnosis is usually clinical.
In patients with chronic urticaria, testing does not usually help to establish a cause, direct management or improve patient outcomes.9 In a study of 356 patients with urticaria referred for allergy and immunology evaluation, only one patient benefited from a change in management due to testing and only 319 (17%) of the 1872 tests ordered had abnormal findings.10
Laboratory testing may be useful in selected patients with chronic urticaria, e.g. if an underlying condition is suspected, they have failed to respond to treatment, or if the condition is severe.9 The choice of investigations should be guided by positive findings from the clinical history and physical examination. Discussion with a dermatologist may also be helpful.
The following investigations may be appropriate for specific clinical circumstances:
Skin prick testing may be considered when an allergic cause for the urticaria is suspected and confirmation would be useful for management, e.g. if avoidance measures are being considered. Skin prick testing should not be performed routinely. Skin prick testing may not be reliable in older adults and children aged under two years should be referred to an allergy clinic for testing as the results may be difficult to interpret. Skin prick testing in pregnant women should only be requested if the benefits outweigh the risks, as in rare cases it can cause uterine contractions.11
Serum allergen-specific IgE testing is second-line to skin prick testing when skin prick testing is unsuitable or unavailable.
For further information see: "Appropriate use of allergy testing in primary care", Best Tests (Dec, 2011)
Full blood count may indicate an allergy or an intestinal infection if the eosinophil count is elevated. Neutropenia may suggest an autoimmune or viral cause, while neutrophilia may be caused by a bacterial infection. Acute viral infections, e.g. Epstein-Barr virus, or autoimmune thyroiditis may cause a high lymphocyte count.
Thyroid antibody testing may be useful following discussion with an appropriate specialist, if a thyroid autoimmune disorder is suspected. Chronic autoimmune urticaria is associated with antithyroid antibodies in approximately one-quarter of cases.3
Skin biopsy (3 mm punch biopsy) is only rarely required, if urticarial vasculitus is suspected or when the diagnosis is uncertain. Atypical features of urticaria include pain or burning rather than pruritis, complete non-response to anti-histamines, wheals persisting for longer than 48 hours, or not fully resolving, with remaining hyperpigmentation.
Best Practice tip: Before contacting a dermatologist, take anatomic views and close-up digital images of the patient's skin lesions. Emailing good quality clinical images may assist the discussion, particularly if the patient's clinical signs are intermittent.
Treatment for urticaria
Acute urticaria generally resolves over a short period of time, however, chronic urticaria can persist for months or even years (particularly physical urticaria). This can be frustrating for both patient and doctor, especially when there is no known cause.
In a study of 220 patients with chronic idiopathic urticaria, it was found that after one year:6
47% were symptom-free
60% with ordinary urticaria and angioedema were symptom free
39% with ordinary urticaria only were symptom free
16% with physical urticaria were symptom free
Management is focused on avoiding triggers where known, and using medicines for symptom relief.
Avoidance strategies
When the clinical history does not reveal an obvious cause for the urticaria, an avoidance strategy for potential triggers may be considered.
Patients can be advised to stop any non-essential medicines, herbal supplements or topical preparations. In particular, aspirin, codeine and non-steroidal anti-inflammatory drugs (NSAIDs) may contribute to wheal formation, even when they are not the primary cause of the eruption. If symptoms resolve (or do not recur), medicines/products can be reintroduced sequentially, if necessary, and the patient should report any return of symptoms.
Dietary investigations rarely identify a specific trigger for chronic urticaria, and are not necessary in cases where symptoms can be easily controlled with oral antihistamines. However, if the patient wishes to, a food diary may be used to record and eliminate suspected triggers. Particularly motivated people may try a narrow diet of rice and a single source of protein for two weeks, while discontinuing all antihistamines. Foods can then be slowly reintroduced and reactions noted in the food diary.1
Pharmacological treatment
Introduction of medicines for the treatment of urticaria should be considered in the following order:
Commence non-sedating oral antihistamines
Add conventional sedating oral antihistamines and/or H2 receptor antagonists
Add tricyclic antidepressants
Add oral corticosteroids - only for patients with severe acute urticaria
Non-sedating oral antihistamines are the first-line pharmacological treatment for both acute and chronic urticaria due to their effectiveness and relative lack of anticholinergic and central nervous system effects. Although referred to as "non-sedating", these medicines may still cause sedation at usual doses in some patients. In New Zealand cetirizine and loratadine are fully-funded (see Table 1 for recommended doses). Individual response to antihistamines may be variable, however, cetirizine is thought to be the quickest acting, therefore may be trialled first.2
Table 1: Recommended doses for fully-funded, non-sedating antihistamines available in New Zealand13,14,15
Antihistamine Adult dose Child dose (6 –12 years) Child dose (2 – 6 years)
Cetirizine 10 mg, once or twice daily* 10 mg, once daily or in divided doses 5 mg, once daily or in divided doses
Loratadine 10 mg, once or twice daily* > 30 kg: 10 mg, once daily
< 30 kg: 5 mg, once daily 5 mg, once daily
* Although the maximum dose in the New Zealand medicine datasheet is 10 mg, this medicine is often used (and required) in higher doses, without any reports of adverse effects, in order to successfully manage urticaria12,16
Oral antihistamines may be taken on an "as-required" basis, due to their rapid onset of action, but may be more effective when taken daily. The recommended maximum adult dose of cetirizine and loratadine is 10 mg per day, however, European guidelines recommend non-sedating antihistamines be prescribed at up to four times the standard dose (i.e. cetirizine or loratadine 40 mg daily) before second-line medicines are considered as adjunctive treatment.12
Sedating oral antihistamines are rarely used as a monotherapy for urticaria, but can be used in combination with non-sedating antihistamines. These medicines may be useful for patients with nocturnal symptoms that prevent sleep. Promethazine (fully funded) is a suitable choice and can be prescribed at the following doses:13,14
Adults; 25 – 75 mg, at night
Children aged five to ten years; 10 – 25 mg, at night
Children aged two to five years; 5 – 15 mg, at night
H2 receptor antagonists such as ranitidine or famotidine, when used in combination with antihistamines, may be of benefit to some people with chronic urticaria as 15% of histamine receptors in the skin are H2-type.3 These medicines are not recommended as monotherapy because their ability to reduce pruritus is limited and there is little clinical evidence of their effectiveness.
Tricyclic antidepressants have histamine receptor antagonist activity and may be especially useful in treating chronic urticaria, in combination with non-sedating antihistamines. Due to its sedating properties doxepin (30 – 50 mg) is an appropriate treatment for nocturnal symptoms. Amitriptyline (10 – 50 mg) may also be effective.
Oral corticosteroids may be added for people with severe acute urticaria. The recommended dose for adults is 20 – 40 mg daily, or for children 1 mg/kg daily, maximum 40 mg, tapering to the lowest effective dose over the course of two to five days.13 Corticosteroids are nearly always inappropriate in people with chronic urticaria as long-term use should be avoided.
N.B. Topical corticosteroids are not useful in the treatment of urticaria and may cause adverse effects with longer-term or higher-potency use, e.g. skin atrophy. Topical antihistamines are also not effective for treating urticaria and are not recommended due to the risk of sensitisation and resulting contact dermatitis.17
Cooling preparations containing 0.5 – 1% menthol in a cream or lotion base, e.g. cetomacrogol cream, may provide symptom relief. The use of cool damp cloths, reduction of night-time heating and tepid showers may also be useful.
Referral for specialist treatment may be considered if the diagnosis is uncertain or where symptoms are severe and poorly controlled. A number of further treatment options are available including immunosuppressants, e.g. cyclosporin, and leukotriene receptor agonists, e.g. montelukast. If a complex drug or food trigger is suspected then consider referral to an immunologist. Phototherapy using ultraviolet B radiation reduces the number of mast cells in the upper dermis,12 and may be effective in reducing symptoms in cases of physical urticaria that are resistant to antihistamines.18 Patients can be referred to a dermatologist for this treatment.
Best Practice tip: A standard treatment regimen for urticaria – begin with cetirizine, if symptoms are not controlled, add promethazine 25 mg at night and raniditine 300 mg during the day. This will settle symptoms for most people. If symptoms still persist, add in a tricyclic antidepressant.
Antihistamines during pregnancy
Ordinary urticaria is uncommon in pregnant women and little is known about the safety of antihistamines in women who are pregnant or breastfeeding. The majority of information that is available concerns the older, first-generation sedating antihistamines. Generally, all antihistamines should be avoided by women who are pregnant, especially during the first and third trimester.17 However, there have been no reports of major birth abnormalities in women who have used newer, non-sedating antihistamines during pregnancy.12 Loratadine (pregnancy category B1)19 may be considered for the treatment of urticaria in women who are pregnant when the benefits of treatment are thought to outweigh the risks.12 Sedating antihistamines may be considered in severe cases of urticaria occurring during pregnancy, if the patient has not responded to non-sedating antihistamines. However, these medicines should be avoided around the time of delivery to reduce the chance of causing sedation in the infant.
Subscribe to:
Posts (Atom)