Urticaria: Duration, Recurrence, and Treatment Insights

Is the phenomenon of urticaria normal?

Hello Dr.
Wu,
Last Saturday night, I suddenly developed a rash.
Initially, I thought it was an allergy and applied some medication on my own.
However, by early Sunday morning, I noticed that the rash had increased significantly, so I went to the emergency room.
The doctor diagnosed me with urticaria (I have no prior history) and administered an injection and IV fluids.
After the IV, the rash noticeably subsided.
The doctor prescribed Acrivastine and Promethazine for three days, assuring me that I would recover after finishing the medication.
Throughout Sunday, I did not experience any recurrence, but the urticaria triggered my rosacea.
On Monday morning, when I visited a dermatologist, I found that the rash had started to reappear.
The doctor prescribed additional medications for urticaria (Cetirizine, Dexamethasone, Promethazine, and Levocetirizine) and informed me that these were long-acting medications (to be taken in the morning and evening) with effects lasting up to 12 hours.
However, after taking the medication around 10 AM, by 4 PM, the rash had worsened.
After taking the medication again in the evening, the rash subsided around 11 PM, but on Tuesday morning, it reappeared.
After taking the medication around 8:30 AM, the rash subsided, but by early afternoon, it started to flare up again.
On Tuesday night, I had to return to the hospital to see a dermatologist.
The doctor suggested that the medication might not be sufficient, so they administered another steroid injection and prescribed Prednisone, Acetaminophen, Levocetirizine, and Hydroxyzine.
After returning home, I noticed that the rash had spread more severely than before (on my chest, back, hands, feet, and palms).
After taking the medication and receiving the injection around 9 PM, some of the rash began to subside by midnight, but new spots also appeared.
This morning, around 6 AM, I noticed some improvement, but by 7 AM, the rash had started to reappear.
After taking medication around 8 AM, the rash began to subside again, but by 1 PM, it started to flare up once more.
I would like to ask:
Q1: How long does urticaria typically last? I thought that with medication, the rash would decrease in severity and duration, but my condition seems to be worsening, with a broader area affected and shorter intervals between flare-ups.
Is this a normal phenomenon? In general, how long does it take for the rash to gradually stop appearing?
Q2: Can recurrent urticaria lead to scarring? I noticed a second rash on the back of my knee yesterday, which has now turned into a dark red patch that has not subsided.
Is this normal?
Q3: The hospital has scheduled a follow-up appointment for a week later, but if my rash continues to worsen and spread, should I consider returning earlier? Or should I finish the week’s medication and then observe? Could this develop into chronic urticaria?
Q4: If I cannot identify the allergen, should I undergo allergy testing?
Q5: My skin was normal before receiving the vaccine, but after getting the Moderna vaccine last February, I have experienced eczema, rosacea, and urticaria.
Could this indicate an issue with my immune system? Should I consult a rheumatologist or immunologist?

Diane, 40~49 year old female. Ask Date: 2023/09/13

Dr. Wu Yuxin reply Dermatology

Such a complex clinical issue is not suitable for online consultation.
It is recommended that you seek a face-to-face consultation with a dermatologist to effectively address the problem.

Reply Date: 2023/09/13

More Info

Urticaria, commonly known as hives, is a skin condition characterized by raised, itchy welts that can appear suddenly and vary in size. Understanding the duration, recurrence, and treatment of urticaria is crucial for managing this condition effectively.

Q1: Duration of Urticaria
The duration of urticaria can vary significantly from person to person. Acute urticaria typically lasts less than six weeks and may resolve on its own, especially if triggered by an allergen or irritant. However, chronic urticaria persists for more than six weeks and can last for months or even years. In your case, the fact that you are experiencing an increase in the number and severity of hives, despite medication, may indicate that your condition is not being adequately controlled. It is not uncommon for hives to flare up at night or after certain activities, which can be frustrating. If your symptoms continue to worsen, it is essential to consult your healthcare provider sooner than the scheduled follow-up.

Q2: Scarring from Urticaria
Generally, urticaria does not lead to scarring. However, if the hives are severe and cause significant scratching, this can lead to secondary skin changes or scarring. The dark red spots you are observing may be a result of the inflammatory process or post-inflammatory hyperpigmentation, which can occur after the hives resolve. It is essential to avoid scratching to minimize the risk of skin damage.

Q3: Follow-Up and Chronic Urticaria
If your hives continue to worsen, it is advisable to return to your healthcare provider before the scheduled appointment. Chronic urticaria can develop if acute episodes are not adequately managed. Your doctor may consider adjusting your treatment plan, which could include stronger antihistamines, corticosteroids, or other medications like omalizumab, which is used for chronic urticaria.

Q4: Allergy Testing
If you cannot identify the triggers for your urticaria, allergy testing may be beneficial. This can help pinpoint specific allergens that may be causing your symptoms. Common triggers include certain foods, medications, insect stings, and environmental factors. Identifying these triggers can help you avoid them and reduce the frequency of hives.

Q5: Vaccine and Immune Response
Regarding your concerns about the onset of skin issues following the Moderna vaccine, it is essential to note that vaccines can sometimes trigger immune responses that may exacerbate pre-existing conditions or lead to new ones. However, this does not necessarily indicate a systemic issue with your immune system. If you suspect that your vaccine may have contributed to your skin conditions, discussing this with a rheumatologist or an immunologist could provide insights into your immune health and whether further evaluation is necessary.

Conclusion
Managing urticaria can be challenging, especially when symptoms persist or worsen despite treatment. It is crucial to maintain open communication with your healthcare provider about your symptoms and any changes you observe. Keeping a diary of your hives, including when they occur and any potential triggers, can also be helpful in managing your condition. Remember, while urticaria can be uncomfortable and distressing, with appropriate treatment and management strategies, many individuals can find relief and improve their quality of life.

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