24yr 1yr ideopathic urticaria controlled initially on plaquenil started after 4mo of steroids. Now has broken thru and has delayed pressure hives which she thinks are a new manifestation any help or suggestions.


Thank you for your inquiry.

Inquiries regarding severe cases of urticaria which are resistant to standard therapy have been submitted to our website quite commonly. Unfortunately there is no easy answer to these, and the only way to pursue such cases is to institute alternative therapy. You have chosen one of these, Plaquenil, which is certainly a good choice. However, now that he is not responding, I think other choices might be indicated.

Personally, at this stage of the game, I quite often will use tacrolimus, but there are other alternatives available for you. These are discussed in two excellent references which are reviews of treatment for resistant chronic urticaria. These references are two back-to-back articles which appeared in the Annals of Allergy, Asthma, and Immunology. They are:

1.Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 1. Volume 100 (Number 5), pages 403-412, May 2008.

2.Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 2. Volume 100 (Number 6), pages 517-526, 2008.

Alternative therapies with dosing and “pros and cons” of each treatment are discussed in detail in these articles. You should find them very helpful in making your next decision regarding potential treatment modalities for your patient.

In addition to the treatments mentioned in these reviews omalizumab has also been used successfully in this disorder.

Annals of Allergy, Asthma & Immunology
Volume 99, Issue 2, August 2007, Pages 190–193

Thank you again for your inquiry and we hope this response is helpful to you.

Phil Lieberman, M.D.

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