Transcript
Brad Glick: I have another question. The question is kind of differential diagnosis. Not all that is hives are hives. Some hives present, they're a little pink, they're juicy, they're edematous, there's a white dermatographism, there's white hives, all these different presentations. What is in your differential diagnosis? What are you thinking of if maybe the patient may not have classical CSU?
Laura Ferris: I think one of the things that I really look for is I do get the history of how long does each lesion last. If they are lasting longer than 24 hours, I'm thinking about urticarial vasculitis, that's going to send me down another pathway. I'm going to probably do a biopsy. I ask patients if their lesions burn or sting or are they really itchy? And then do they heal with a bruise? So, absent that, then I'm really more in just the standard urticaria pathway. I do ask about physical triggers because we do have chronic inducible urticaria also that we need to put into the differential because that can help guide treatment as well. And then, of course, I'm looking for the totally the zebra, the weird fever syndrome, the thing that just doesn't seem right. This was a healthy person and all of a sudden they're getting hives versus somebody who's had this all their life or it's associated with a lot of things like joint pain or fevers.
Brad Glick: Yeah, I think for urticarial vasculitis, the presentation is going to be a little bit different. I think those patients can have a little bit more pain than they do itch. They may have a low grade fever, their joints might hurt them a little bit more too. And so I think it's a different type of symptomatic presentation. Anything else in the differential for you?
Lawrence Green: Agree. In private practice, I would be even more basic. Urticarial vasculitis is much less common than CSU. So, yes, I think about it with bruising and pain and all those things, but you're looking for urticaria, number one, with the patient. And it's important, I think, to distinguish that 24 hour you mentioned, or because patients will think that 24 hours means lesions all the time. You have to make it very clear that individual lesions have to be present for a few hours, or often I say even a few hours, then they go away, but you keep getting new ones throughout the day, and that's important to help distinguish urticaria from other conditions.
Brad Glick: CSU particularly, spontaneous as is the hashtag, and then unpredictable as well, too. Let's talk about a little bit about angioedema because that's a term that some of our colleagues and definitely our primary care colleagues will get. They'll get a little bit nervous. They might think that it's angioedema, might be associated with anaphylaxis. They get nervous. About 30% of our patients who have CSU are going to have some angioedema, but I think it's a little bit different. What are your thoughts about that? What do you tell your patients when you see that?
Lawrence Green: I'll start. Scary angioedema is very scary, but that's very uncommon when someone's throat is closing or something like that. And that's very rare that you see that. And again, in private practice, I don't think that I've never seen that happen. I doubt that's going to happen. That would be, maybe, Laura, you have more experience, but of course I ask about it. "Do you ever have difficulty swallowing? Does your throat feel like it's closing?" But I think it's much less common. It's something you have to ask about, but not worry too much about.
Laura Ferris: True CSU does not, you don't need to worry about airway compromise.
Brad Glick: Right. And I think that when we see angioedema associated with urticaria, it's transient as well. However, to my knowledge, it will lag a little bit behind the hives, last a little bit longer, maybe about 72 hours. But I think we have to educate our patients that it's not that type of reaction that you would see if you're allergic to penicillin and you're having an allergic reaction, hence our discussion about the fact that this is not an allergy, and I think it kind of segues very nicely in the discussion of angioedema as well. How do we as dermatologists get a little bit more comfortable with managing these patients and retaining them? And for that matter, as a group of patients that have this condition, for them even to really be comfortable coming into our settings?
Lawrence Green: I'll start with private practice. I mean, I think everyone's going to try second-generation antihistamines first, twice a day or something like that, and that's not usually going to work in CSU, but then there are great options. We talked about omalizumab, but some people may still be uncomfortable. We have other medications now, like remibrutinib, which are very easy to administer, don't require any labs or testing, and it's an oral product. And we have dupilumab, which every dermatologist is very familiar with that makes, also no monitoring needed. So we have two medications that are very easy to use and something we're very comfortable using and easy for the patients. So it's not difficult and it's an easy thing to offer our patients. That's what I would say.
Laura Ferris: Agree. Yeah, make them better. That's how we bring them back. We make them better.
Brad Glick: And nice to have choices because if you think about it in terms of FDA approved therapies, we've had the older injectable we've been talking about. We haven't talked too much about dupilumab, but of course, revolutionary therapy starting with atopic dermatitis, multiple indications. And it brings up the other kind of discussion point about comorbidities. If someone has background asthma and they happen to have CSU as well, which we can see in a percentage of our patients with CSU, then we've got great choices in an agent like dupilumab to be able to use for those patients.
