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Urticaria

Clinical Cases

Case 1

  • 12-year-old girl
  • 3-day history of pruritic urticarial lesions on chest, back, and abdomen
  • No associated symptoms of fever, shortness of breath
  • 1 week ago: 2-day history of sore throat
  • No medications

Initial treatment

  • Start loratadine 10 mg daily
  • Rapid throat culture for Group A streptococcus
  • Follow-up evaluation in 1 week

Follow-up evaluation at 1 week

  • Urticaria are improved, but ongoing
  • Rapid streptococcal throat culture result: positive
  • Antibiotics are given to treat the streptococcal pharyngitis
  • Escalate dose of loratadine
  • Follow-up evaluation in 2 weeks

Follow-up evaluation at 2 weeks

  • Patient reports intermittent urticaria with two episodes over the past 2 weeks
  • Switch to another non-sedating antihistamine, cetirizine 10 mg
  • Follow-up evaluation in 2 weeks (urticaria resolved)

Case 2

  • 14-year-old girl
  • 2-month history of intermittent pruritic urticarial lesions on back, chest, arms, occasionally on legs
  • Lesions are migratory, lasting 1 day
  • No associated symptoms of fever, arthralgias, shortness of breath
  • No significant past medical history or current disease
  • Detailed history and physical exam does not reveal signs of local disease
  • Takes occasional ibuprofen for headaches

Initial treatment

  • Start fexofenadine 15-180 mg daily
  • Discontinue ibuprofen
  • Follow-up evaluation at 2 weeks

Follow-up evaluation at 2 weeks

  • Patient reports slight improvement of intermittent urticaria but still having multiple episodes since last clinic visit
  • Escalate dose of fexofenadine
  • Blood test: complete blood count with differential, ESR
  • Follow-up evaluation at 4 weeks

Follow-up evaluation at 4 weeks

  • Patient reports ongoing improvement
  • Blood test results show slightly elevated ESR
  • Add montelukast 4-10 mg daily
  • Follow-up evaluation at 4 weeks (improved)