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Bilastine provides symptom control, improves quality of life in adults with delayed pressure and cholinergic urticaria

Dr. Ch’ng Chin Chwen
University of Malaya Specialist Centre
Prof. Maria Teresita Gabriel
Research Institute for Tropical Medicine Philippines
17 Oct 2016
Case 1
Presentation
A 42-year-old Pakistani female consulted for spontaneously occurring generalized wheals of 6 months duration. She noticed that the wheals mostly appeared on her upper body and were erythematous, painful, pruritic, and unsightly.

She reported that the symptoms interfered with her daily activities, especially her studies and functions as a PhD student. The condition affected her social relationships and made her conscious of her physical appearance. She had difficulty maintaining her personal chores and choosing her cosmetics and clothes.

She noted that the wheals erupted after sustained pressure is applied on her skin. Her rashes were also triggered by unrecalled types of food. The symptoms were accompanied by mild and infrequent gastric discomfort without changes in bowel habit.

She had no exposure to animal dander, pollen, or industrial chemicals. Her family history was negative for atopy and she did not have previous treatment for allergies.

She self-medicated with over-the-counter (OTC) antihistamines and avoided the triggers, resulting in limited improvement. She consulted a generalist who advised her to continue the OTC medications after blood tests revealed nonspecific findings. Her lesions persisted despite compliance prompting her to seek consult.

Physical examination showed multiple plaques with smooth surface and polycyclic curved borders especially around her neck where she wore necklace and on the bra strap lines. She had no discharges from her ears, eyes, nose, and throat. The rest of the physical findings were unremarkable. She was diagnosed with delayed pressure urticaria.

Management

She was prescribed with bilastine 20 mg to be taken once daily for 7 days. On follow-up after 1 week of treatment, there was remarkable reduction in the number of wheals (Figure 1).

Bilastine_Fig 1

She experienced less pruritus with only lingering itch on some parts of her body. She reported less difficulties in her day-to-day activities, less anxiety, better sleeping pattern, improved concentration and mood, and increased energy when doing her tasks at the university. She expressed satisfaction with the improvement on her skin. She was less self-conscious and was no longer limited by her choice of clothes and cosmetics.

She was advised to continue with bilastine 20 mg once daily for 7 days. She returned after 1 week with some recurrence of symptoms but to a lesser extent. To address these symptoms, bilastine was adjusted to 40 mg once daily, with regular follow-up every 2 to 4 weeks.

Case 2
Presentation
A 28-year-old Filipino female patient sought advice due to recurrent miniature wheals on her trunk after a physical activity, specifically dancing. She noted that less than 20 wheals appear in a day with spontaneous resolution. There was associated mild pruritus without swelling or pain. She complained of moderate difficulty in sleeping due to itching, which awakens her. She also felt that the rashes were affecting her physical appearance.

She has been experiencing these symptoms since she was 20 years old. She was diagnosed with atopic dermatitis but did not need long-term allergy medications. She takes antihistamine occasionally for pruritus.

Physical examination showed pinpoint hives and dermographism. The rest of the physical examination were normal.

Management
She was advised to take bilastine 20 mg twice daily and to return after 1 week. On follow-up, there was complete resolution of the rashes and alleviation of the pruritus (Figure 2).

Bilastine_Fig 2

She had better sleep, felt less tired, and did not have any limitations with her daily activities, especially dancing. She observed that her skin substantially improved and she did not have any problem with her choice of cosmetics and clothes.

Discussion
Delayed pressure urticaria is a physical type of urticaria characterized by the appearance of erythematous and painful swellings over skin sites receiving sustained pressure such as areas covered by tight clothes, on palms after using tools, and soles of feet after prolonged walking. The pruritic lesions develop after a delay of 30 minutes to 12 hours and may persist for several days. Flu-like symptoms and arthralgia may also be present. Approximately 40 percent of patients with chronic urticaria have associated delayed pressure urticaria.1

The pathogenesis of delayed pressure urticaria is not well-defined but previous studies suggest that the pressure-induced wheals are dependent on mast cell activation. Histological data also show deep dermal inflammation with neutrophil and eosinophil infiltrates.1

Delayed pressure urticaria can severely interfere with a person’s quality of life. Its treatment is generally difficult and therapy using antihistamine and anti-inflammatory medications have produced unsatisfactory results.1

Cholinergic urticaria, also called generalized heat-induced urticaria, is a physical urticaria triggered by exercise, sweating, and hot baths or showers. The skin lesions are small and severely pruritic. In severe cases, cholinergic urticaria may cause hypotension and overlap with the syndrome of exercise-induced anaphylaxis.2

The goal in the management of urticaria is complete symptom control.3 Changes in the patient’s health-related quality of life (HRQoL) is also an important parameter in evaluating symptom improvement.4 Treatment guidelines for urticaria developed by the Asian Academy of Dermatology and Venereology (AADV), European Academy of Allergy and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) recommend the use of novel second-generation antihistamines, such as bilastine, over first-generation antihistamines.3

In the case of our patient with delayed pressure urticaria, bilastine treatment resulted in satisfactory symptom response and improvement in quality of life. Her clinical response is aligned with the findings of trials evaluating the effect of bilastine in the HRQoL of patients with urticaria. Bilastine is an effective option in the management of urticaria and contributes to improving the HRQoL in patients. It is a nonsedating drug and does not interact with the cytochrome P450 system.4

The recommended dose of bilastine is 20 mg once daily. In our patient with delayed pressure urticaria, the dose was increased to 40 mg once daily after 1 week of treatment at the recommended dose. According to the AADV/EAACI/GA2LEN/EDF/WAO guidelines, the dose of bilastine can be increased up to fourfold in severe cases of urticaria.5

In the case of our second patient with cholinergic urticaria, bilastine was effective in resolving the presence of wheals and pruritus as well as in reducing general discomfort and sleep disruption. Large randomized trials have shown that bilastine has a rapid onset of action and a duration of effect up to 24 hours. Bilastine reduces the total symptom scores for pruritus, the number of wheals, and the maximum size of wheals.6

Bilastine is an effective treatment option for delayed pressure and cholinergic urticaria. It improves the HRQoL and does not cause drowsiness or sedation. Bilastine is well-tolerated and does not interact with cytochrome P450.4-6 Increasing the dose of bilastine up to fourfold is beneficial for patients with severe urticaria if standard dosing is ineffective.7
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