Brief Answer:
Chronic urticaria

Detailed Answer:
Hello XXXXXXX

I have had unexplained generalized itching in the past, that can last for several months at a time. Is your rash and itching generalized, or in a specific area?

If the itching is generalized, if not already done, it would be a good idea to check for thyroid disease with a blood test (TSH, T4 or T3 and anti-thyroid antibodies), and for other sources of autoimmune disorders. Also a serum tryptase level.

Has there been anything new in your environment (or diet) prior to the onset of this problem? New pet? New meds? New lotion?

You might also want to see an allergist for allergy testing, although the regular allergy skin testing wouldn't be accurate given that you are on antihistamines, but I think a serum RAST test might be doable while you are on antihistamines.

Regarding diet, when these episodes happen for me, I find that foods that I am not even allergic to can cause itching, by a different mechanism (mast cell activation). During those times, I avoid foods with strong spices, garlic, tomatoes, fermented foods such as soy sauce.

The puffy eyes and face sounds more extreme. Steroids (prednisone) can cause one's face to look round, like the moon, but usually not puffy eyes too. This sounds more like a reaction to something.

You may want to change your diet to a very elemental diet and then slowly add back things and see if you can identify anything that is a problem.

Foods that are usually tolerated in allergic situations and in mast cell activation disorder are rice, plain chicken, fish (not fried, no shell fish), and most vegetables (except strong tasting ones such as asparagus). Potatoes are usually ok too. Cook with a mild oil such as Canola to start with, and only add spices, garlic, onions after you have been on the simple foods for a week. And add foods one at a time.

Other medications can be added that can help. Commonly, the allergy medicine Singular (montelukast) can help some people. It is not an antihistamine, but rather a leukotriene receptor antagonist and is a safe drug with low risk of side effects.

Another medication that can be added safely is the H2 blocker Zantac (ranitidine) which is normally used for stomach acid. It targets different histamine receptors in the skin (H2 receptors) than antihistamines (H1 receptors).

I'm copying an article about chronic urticaria here - please let me know if you can't open it: http://emedicine.medscape.com/article/0000-treatment#d9

And here is another good article about treatment option sequencing:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/

I've found that not all allergists or dermatologists are expert or up to date on treatment for this, so you may have to become knowledgeable and your own advocate.

I know it's horribly miserable and can be incapacitating. But there is hope, and you might feel better with soon with some modifications to diet and medicines.

I would be happy to explain any of the terminology or concepts in the articles.

About the itching after the hydroxyzine - I don't know what is going on with that. I have experienced something similar, only milder, after taking cetirizine (another antihistamine). I can't explain it. It sounds like your reaction to is is worse though.

---

Brief Answer:
Information

Detailed Answer:
Zantac 150 mg is sold without prescription.
Singulair still requires a prescription.

I'm glad you use hypo-allergenic (scent free?) laundry detergent. I would add that if you use dryer sheets or fabric softener to avoid those.

I'll copy the first article below. If it comes out please let me know and I'll copy and paste the second article. Alternatively, you might be able to view the links if you copy and paste the link into the search bar (the place where you type in links or addresses for searching on the web).

--------------------------------------------------------------------------------------------
Chronic Urticaria Treatment & Management (from e-medicine/medscape)

Approach Considerations

Nonsedating anti-H1 antihistamines remain the mainstay of treatment for chronic urticaria. If these agents are ineffective, higher dosages may be tried, or other agents may be substituted (see below).

Avoidance of mental stress, [23] overtiredness, alcohol, nonsteroidal anti-inflammatory drugs (NSAIDs), and tight-fitting garments is recommended. Psychological stress can trigger or increase itching. [23] Nocturnal pruritus may be reduced by lukewarm bathing and keeping the ambient temperature of the bedroom cool. Application of lotions with menthol and phenol provide prompt relief of pruritus for some patients.

Pharmacologic Therapy
Antihistamines

The mainstay of pharmacotherapy for chronic urticaria is the administration of low-sedation anti-H1 antihistamines (eg, loratadine, cetirizine, levocetirizine, and fexofenadine), which have a low incidence of adverse effects. [24, 25] Quality of life appears to be improved more by daily therapy than by therapy administered on an “as needed” basis. [26]

Low-sedation antihistamines decrease the intensity of hives and pruritus in patients with mild chronic urticaria and are considered first-line therapy. Crossover studies comparing the suppression of skin papule and erythema formation induced by intradermal histamine injection after a single antihistamine dose suggest the following order of inhibitory effect: (1) levocetirizine, (2) cetirizine, (3) terfenadine, (4) fexofenadine, and (5) loratadine.
The potency of an antihistamine in inhibiting wheal and erythema formation response to intradermal histamine injection is correlated with the skin concentration of the drug rather than the plasma concentration. Sedation and impairment of performance are concerns when sedating antihistamines are used, but these adverse effects may diminish after 1-2 weeks of therapy.
Many patients find that pruritus is less troublesome during the day but is maximized at night, when there are fewer distractions. An additional nocturnal dose of a sedative antihistamine such as hydroxyzine or doxepin may be added to the morning dose of a low-sedation anti-H1 antihistamine. Doxepin should not be used in patients with glaucoma and should be used with extreme caution in elderly patients or those with heart disease.

Doubling the labeled dose of low-sedation antihistamines may benefit some patients, and increasing the dose of these antihistamines is often the safest therapeutic approach for patients who do not have an adequate response to the conventional doses of these medications. Increasing the dosage up to 4-fold is recommended by expert groups such as the European Academy of Allergy and Clinical Immunology (EAACI). [23]

As many as 75% of patient with chronic urticaria referred to tertiary care centers may require higher than conventional antihistamine doses. [27] These higher nonsedating antihistamine doses improved quality of life but did not increase somnolence. [27]

If high-dose nonsedating antihistamine therapy is not effective, switching to a different nonsedating antihistamine or adding a leukotriene antagonist (see below) to the antihistamine regimen may be considered. [23] Patients who do not respond to 20 mg of desloratadine may benefit from 20 mg of levocetirizine. [27]

Use in pregnant women

Cetirizine and loratadine are category B agents; nevertheless, a first-generation antihistamine such as chlorpheniramine may be considered the drug of choice in pregnant women because the cumulative experience with use of such agents in this population is greater.

Use in patients with kidney or liver impairment

For cetirizine, 60% of an administered dose is eliminated via the kidneys; for levocetirizine, the figure is 85%. Most H1 or H2 antihistamines undergo presystemic metabolism in the liver via cytochrome P-450. Accordingly, reduction of low-sedation antihistamine doses is advised in patients with liver or renal failure.

Use in children

Cetirizine and fexofenadine are approved by the US Food and Drug Administration (FDA) for chronic urticaria in children aged 6 months and older. Desloratadine is approved for chronic urticaria in children aged 1 year and older. Loratadine is approved for chronic urticaria in children aged 2 years and older. Levocetirizine is approved for chronic urticaria in children aged 6 years and older.

Hydroxyzine has been used to alleviate pruritus in children with atopic dermatitis and is an appropriate second-line agent in children with chronic urticaria that is refractory to low-sedation antihistamines.

Leukotriene antagonists

Leukotriene antagonists have been shown to be superior to placebo in the treatment of patients with chronic urticaria but are considered less effective than nonsedating antihistamines [2, 3] ; however, the 2 classes of agents can be combined. Montelukast 10 mg/day may be particularly helpful for patients experiencing flareups due to aspirin or other NSAIDs. Montelukast is approved for treatment of perennial allergic rhinitis in children aged 6 months and older.

Colchicine and dapsone

Patients who respond poorly to antihistamine therapy or who are known to have urticaria in which the inflammatory infiltrate is neutrophil-predominant (except those with glucose-6-phosphate dehydrogenase [G6PD] deficiency) may require the addition of colchicine (0.6 mg twice daily) or dapsone (50-150 mg once daily) to the treatment regimen.

Systemic corticosteroids

Systemic corticosteroids are usually effective when antihistamines are not adequate. In the rare situation where systemic corticosteroid treatment is needed to treat chronic urticaria, a low daily dose or alternate-day dosing is advised, and the dose should be titrated to the lowest effective level. In general, long-term systemic corticosteroids are not recommended. [23] Patients receiving long-term corticosteroid therapy should be routinely monitored for bone density changes and adverse ocular effects.

Cyclosporine and methotrexate

Patients with autoimmune urticaria may benefit from administration of methotrexate or cyclosporine. [5, 4] Cyclosporine 4-6 mg/kg/day has been shown in randomized double-blind studies to be effective for chronic urticaria. Cyclosporine has a better risk-to-benefit ratio than systemic corticosteroids. [23]
Cyclosporine is recommended only for patients with severe disease refractory to high doses of oral antihistamines. Cyclosporine therapy for chronic urticaria should be limited to 3 months or less. A sustained remission is observed in approximately one third of patients treated with this medication.

Levothyroxine

Some patients with chronic urticaria and antithyroid antibodies benefit from levothyroxine treatment, perhaps because of suppression of thyroid activity and, possibly, the autoimmune process. The goal of treatment is to suppress thyrotropin maximally without rendering the patient clinically hyperthyroid. The urticaria may respond within 2 weeks of initiation of adequate treatment. Some patients may maintain a sustained remission after 3-6 months of treatment, at which point the levothyroxine can be tapered and then discontinued.

Monoclonal antibodies

Omalizumab (Xolair) was approved by the US Food and Drug Administration (FDA) in March 2014 for chronic idiopathic urticaria in adults and children aged 12 years or older who remain symptomatic despite anti-H1 antihistamine treatment. It is a monoclonal antibody that selectively binds to immunoglobulin E (IgE) and inhibits binding to IgE receptors on the surface of mast cells and basophils. The efficacy and safety of omalizumab for chronic idiopathic urticaria was demonstrated in 2 clinical studies that showed omalizumab significantly improved the mean weekly itch severity score (ISS) from baseline by 9.4-9.6 in the 300-mg treatment arm, by 6.4-6.7 in the 150-mg treatment arm, and by 5.9-6.5 in the 75-mg treatment arm, compared with an improvement of 3.6-5.1 in patients on placebo. [28, 29]

Vitamin D

High-dose vitamin D add-on therapy may provide relief in some patients with chronic urticaria. In a 12-week prospective study of 42 patients with chronic therapy receiving standard triple-drug therapy (cetirizine, ranitidine, and montelukast), those randomized to supplementation with high-dose vitamin D3 (4,000 IU/d) had a trend toward lower total symptom severity scores at the end of the trial (significant reduction in hive body distribution and duration, improved pruritus, and improved sleep quality) compared with patients randomized to low-dose vitamin D3 supplements. [30, 31]
Although baseline total Urticaria Symptom Severity (USS) scores were similar between the 2 groups, and each group had a 33% reduction in total USS scores on triple-drug therapy at 1 week follow-up, by 12 week follow-up, the high-dose vitamin D3 group showed an additional 40% decrease in total USS scores that was not seen in the low-dose group.[2, 3] Despite an increase in levels of serum 25-hydroxyvitamin D with high-dose vitamin D3 supplementation, there was no corresponding association between 25-hydroxyvitamin D levels and USS scores. No adverse events were reported, and medication use in both groups remained similar. [30, 31]

Consultations

A consultation with an allergist is recommended when the eliciting factor seems to be food sensitivity.

Clinical Guidelines

The XXXXXXX Academy of Allergy, Asthma, and Immunology (AAAAI) and the European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA2LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO) have both updated their guidelines for managing chronic urticaria. [32] While some differences in their recommendations exist, the core recommendations remain similar.

A brief summary and highlights of the AAAAI guidelines are as follows:

Second-generation nonsedating H 1 antihistamines as first-line treatment

First-generation H 1 antihistamines remain in the treatment algorithm (differs from EAACI/GA 2LEN/EDF/WAO guidelines)

Equally weighted second-line options to consider: Up-dosing second-generation H 1 antihistamines; adding other second-generation H 1 antihistamines; adding H 2 antagonists, leukotriene receptor antagonists, or first-generation H 1 antihistamines at bedtime

Third-line treatment option is omalizumab

Corticosteroids considered only for the short-term intervention; avoid as long-term treatment

Acknowledged role for cyclosporine A as add-on for refractory chronic urticaria not responsive to other treatments

A brief summary and highlights of EAACI/GA2LEN/EDF/WAO guidelines are as follows:

First-line treatment is second-generation H 1 antihistamines

Second-line therapy is up-dosing second-generation H 1 antihistamines

Third-line treatment is omalizumab, which is recommended before the more toxic cyclosporine A

H 2 antihistamines not included in algorithm (used only on an individual case basis but not as first-, second-, or third-line treatment)

Avoid first-generation H 1 antihistamines based on benefit-to-risk ratio

Corticosteroids considered only for the short-term intervention; avoid as long-term treatment

Acknowledged role for cyclosporine A as add-on for refractory chronic urticaria not responsive to other treatments

In March 2015, the Standards of Care Committee of the British Society for Allergy and Clinical Immunology published guidelines on treatment of chronic urticaria. [33] Management must include the identification and exclusion of possible triggers, patient education, and a personalized management plan.

Often, food allergy can be excluded as a cause of urticaria if no temporal relationship exists to a particular food trigger, by either ingestion or contact. Food additives rarely cause chronic urticaria. Certain drugs may cause or aggravate chronic urticaria; therefore, a detailed drug history is mandatory.

Up to 50% of chronic urticaria cases in older children and adults are reported to be autoimmune in nature, and these may be associated with other autoimmune conditions such as thyroiditis. Autoimmune and some inducible weals can follow a more protracted course and may be more resistant to treatment.

Antihistamine doses at higher than normal levels may be required to control severe urticaria. An increased dose of a single antihistamine is preferred over mixing different antihistamines.

For adult patients with weals, check that symptomatic episodes have not followed ingestion of an NSAID (eg, aspirin, ibuprofen). Provide an explanation for the symptoms and reassure that the histamine-induced chronic urticaria symptoms do not involve the respiratory tract or cardiovascular system, such as occurs in anaphylaxis. Note that very rare exceptions to this rule do exist. A once-daily dose of a long-acting, nonsedating antihistamine should be given, as necessary, if symptoms are infrequent. If necessary, double the antihistamine dose (usually given at night), and/or add a second antihistamine. Consider (1) further increases of antihistamine doses (≤ 4 times recommended), (2) adding one or more second-line drugs, and/or (3) short-term oral corticosteroid rescue treatment.

For chronic urticaria in children, the primary strategy should be avoidance of known provoking stimuli. The mainstay of treatment for children with chronic urticaria is nonsedating antihistamines; up to 4 times the recommended dose may be required for adequate symptom control. In patients who do not respond to high-dose antihistamine therapy, consider the possibility of an underlying diagnosis such as vasculitis.

For chronic urticaria in pregnancy and breastfeeding, antihistamine treatment can possibly be reduced, as chronic urticaria often improves in pregnancy. Note, however, that in some rare cases it deteriorates. While the risks of prenatal urticaria treatment are small, pregnant women should be informed that no drug can be considered absolutely safe. Antihistamines should only be used if clearly needed. If an antihistamine is required in pregnancy, the lowest dose of chlorphenamine, cetirizine, or loratadine should be used. In breastfeeding mothers, either cetirizine or loratadine at the lowest effective does is recommended. If possible, avoid chlorphenamine in breastfeeding.

[There is additional information at the end of this article, detailing how all of the drugs that were mentioned work but it is very long. I can copy and paste it if you would like it.]

---