A Challenging Case of Recurrent Urticaria with Multiple Relapses: Lessons from a Prolonged Road to Recovery

Dr Ojasvi Singla

ABSTRACT
Urticaria is a difficult-to-manage dermatological condition often characterized by pruritic wheals with recurrent relapses. This case report describes a 56-year-old female suffering from generalized itching and multiple relapses since February 2023. The patient, having comorbid diabetes mellitus and psychological grief, was treated with Individualized Homoeopathic Medicines. Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and Urticaria Activity Score over 7 days (UAS7) were assessed every 6 months to monitor disease impact and treatment response. Over a prolonged treatment period, symptom intensity reduced with longer medication-free intervals, culminating in no relapses in the last 6 months.

KEYWORDS : Chronic urticaria, Homoeopathy, CU-Q2oL, UAS7, Case report

INTRODUCTION
Urticaria or hives presents with sudden onset itching and wheals and can be acute or chronic. Chronic Spontaneous Urticaria (CSU) involves wheals lasting over six weeks without external triggers, posing management challenges due to frequent relapses.^[¹^,²^] Conventional therapies primarily include antihistamines and immunomodulators, but long-term relief is often elusive.^[²^] Individualized homoeopathic treatment gaining attention as a safe adjunct promises symptom reduction and improved quality of life.^[³^,⁴^] Reports demonstrate homoeopathy’s immunomodulatory potential and holistic approach considering mental-emotional factors influencing urticaria.^[³^,⁵^,⁶^] This case report presents a complex case of recurrent urticaria managed over two years with homoeopathy complementing allopathic care.^[³^,⁵^]

PATIENT INFORMATION
A 56-year-old female presented on 27/01/2024 with generalized itching since February 2023. Past medical history revealed diabetes mellitus (on allopathic treatment), cholecystectomy 35-40 years prior, and hysterectomy for uterine fibroids 12-13 years ago. She was grieving the recent death of her son in December 2023. Family history suggested suspected liver cancer.

CLINICAL FINDINGS
The patient reported itching aggravated mostly at night and after bathing, with redness developing after scratching. She also experienced throat hoarseness post sour/cold food intake and intermittent facial darkening. Physical examination revealed hyperpigmentation on lower limbs and frothy urine. Blood tests showed elevated random blood sugar and HbA1c.

DIAGNOSTIC ASSESSMENT
Diagnosis was based on clinical presentation. No invasive investigations were performed.

TOTALITY OF SYMPTOMS
Patient presented as-

1. Grief due to loss of her son
2. Reserved nature
3. Anxiety at night
4. Appetite decreased
5. Urine- frothy
6. Sleep disturbed due to itching
7. Itching generalized <night
8. Redness of skin after scratching
9. Throat pain <sour, cold food
10. Black discoloration on left foot

CASE PROCESSING
The totality of symptoms was formed through a holistic evaluation of the patient’s physical and emotional state, with particular emphasis on the profound grief over her son’s loss. Key physical symptoms such as generalized itching, skin redness after scratching, hyperpigmentation, and throat discomfort were considered alongside emotional factors. The case was processed by prioritizing the most distinctive and intense symptoms, especially the grief, which guided the individualized treatment in line with classical homoeopathic principles of addressing the whole person.

TIMELINE AND THERAPEUTIC INTERVENTION
The treatment started with Natrum Mur 200 and followed by Sac Lac. Over the course of follow-up visits through 2024 and 2025, Individualized Homoeopathic Medicines were prescribed based on changing symptoms and patient response [See Table 1]. Allopathic medications continued intermittently for symptom control. Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL) and Urticaria Activity Score over 7 days (UAS7) were assessed every 6 months to monitor disease impact and therapeutic response [See Table 2,3].

The patient experienced initial short-lived relief from homoeopathy but over months demonstrated prolonged symptom-free intervals and decreased relapse frequency. The need for allopathic medications progressively reduced.

Prescribing indications and follow-ups:

First prescription in January 2024-

Natrum Mur 200/ 1 dose/ orally/ empty stomach in morning

• generalized itching, redness after scratching
• grief related to death of her son

Patient showed some relief, but then at standstill. No major improvement till July

Severe aggravation of symptoms in July 2024, Next prescription-

Crotalus horridus 200/ 1 dose/ orally/ empty stomach in morning

• right side hyperpigmentation on lower limbs
• was suspicious that doctors hid something about son’s death
• frequent throat pain
• religious

Patient reported improvement in symptoms until January 2025 and then again condition worsened, symptoms relapsed. Next prescription-

Pulsatilla Nigricans 200/ 1 dose/ orally/ empty stomach in morning

• desire for company
• weeping tendency
• want of reassurance from the doctor
• anxiety about health

RESULTS AND DISCUSSION
The initial assessment revealed a CU-Q2oL score of 65 (indicating moderately high impact on quality of life) and a UAS7 score of 37 (reflecting very active disease with intense wheals and itching). These scores demonstrated the significant burden of recurrent urticaria on the patient’s daily functioning and well-being.

At the end of the treatment period, the patient achieved a CU-Q2oL score of 0, reflecting complete resolution of quality-of-life impairment, and a UAS7 score of 0, indicating the absence of wheals and pruritus for at least 7 consecutive days. This quantitative improvement corresponded with the patient’s reported symptom relief, prolonged symptom-free intervals, and no relapses in the last 6 months.

These findings underscore the value of combining clinical symptom scores with disease-specific quality of life assessments to monitor treatment response and guide management decisions in chronic urticaria. The significant reduction in scores aligns with previous research highlighting the usefulness of CU-Q2oL and UAS7 in reflecting patient-centered outcomes and disease control.

CONCLUSION
Individualized homoeopathy can be an effective adjunct in managing recurrent, chronic urticaria, reducing relapse frequency and reliance on allopathic medicines. Further studies are warranted to validate these findings.

PATIENT CONSENT
Informed consent was obtained from the patient for publication of this case report and accompanying images.

PATIENT PERSPECTIVE
During my treatment and recovery, the rash and itching caused a lot of discomfort and made life difficult at times. The itching was often so strong that it was hard to stop scratching, which made me feel restless and tired. The rash sometimes spread or came back unexpectedly, which made me feel worried and unsure about when I would start feeling better. Everyday activities were affected because the itching disturbed my sleep, making me feel tired during the day. It was frustrating not knowing when the rash would come back, but the care and attention from my doctor gave me hope throughout the long recovery. I am very grateful to my doctor for the dedication, patience, and expertise that helped me find relief and regain my confidence.

REFERENCES

1. 1. Zuberbier T, Aberer W, Asero R, et al. The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2018;73(7):1393-1414.
   2. Maurer M, Abuzakouk M, Aguilar D, et al. Management of difficult-to-treat urticaria. Allergy. 2020;75(12):2822-2830.
   3. Rath P, Parul P. Homoeopathic treatment of chronic urticaria – A case series. Indian J Res Homoeopathy. 2023;14(4):267-278.
   4. Sharma G, Kumar S. Assessment of the effectiveness of homoeopathic remedies in chronic spontaneous urticaria patients. Indian J Res Homoeopathy. 2023;12(3):105-114.
   5. Sonny R, Parui P. Immunoglobulin E modulatory effect of individualised homoeopathy in a child suffering from immunological, chronic spontaneous urticaria: A case report. Indian J Res Homoeopathy. 2025;19(2):45-50.
   6. Patel S, Mehta N, Patel A. Homoeopathy in the treatment of chronic spontaneous urticaria: A review. Homoeopathic Links. 2020;33(2):58-64.

TABLE 1: Key Follow-ups and Prescriptions

Date	Key Follow-ups	Medicine Prescribed
10/03/2024	Itching persists, hoarseness reported	Natrum Mur 200
05/05/2024	Itching severity decreased, skin hyperpigmentation noted	Sac Lac 30
20/07/2024	Itching increased again	Crotalus horridus 200
15/10/2024	Improved sleep, less redness and wheals, symptom-free intervals increased	Sac Lac 30
30/11/2024	Maintenance of symptom control, minor itching episodes	Sac Lac 30
10/01/2025	Symptoms aggravated, taking allopathic medicine daily.	Pulsatilla Nigricans 200
20/02/2025	Reduced itching intensity, improved pigmentation, taking allopathic medication once in 3-4 days	Sac Lac 30
15/04/2025	No wheals observed, minor itching episodes, no allopathic medication needed	Sac Lac 30
05/08/2025	No relapses or itching; CU-Q2oL and UAS7 scores zero	Sac Lac 30

TABLE 2: CU-Q2oL Before and After Treatment

Domain	Items	Response Scale (Scores 0-4) 0 = Not at all, 1 = A little, 2 = Rather, 3 = A lot, 4 = Very much
		At start of treatment (27/01/24) = 65	At end of treatment (05/08/25) = 0
Itching (Pruritus)	1. Itching	4	0
	2. Wheals	4	0
Swelling	3. Swelling of eyes	0	0
	4. Swelling of lips	0	0
Impact on Life Activities	5. Work	4	0
	6. Physical activities	4	0
	7. Sleep	4	0
	8. Free time	4	0
	9. Social relationships	3	0
	10. Eating	4	0
Sleep Problems	11. Difficulty falling asleep	4	0
	12. Waking up at night	4	0
	13. Daytime tiredness due to poor sleep	2	0
	14. Difficulty concentrating	2	0
	15. Feeling nervous	2	0
Limitations	16. Feeling miserable	4	0
	17. Limiting food choices	4	0
	18. Being bothered by hives symptoms	4	0
Appearance	19. Embarrassed to go to public places	2	0
	20. Problem using cosmetics	0	0
	21. Limiting clothing choices	3	0
	22. Limited sports activities	0	0
	23. Side effects from medications	3	0

TABLE 3: UAS7 Before and After Treatment

Day	At start of treatment (28/01/24-3/2/24) = 37 (Severe Urticaria)			At end of treatment (30/7/25-05/08/25) = 0 (Urticaria free)
	Number of Wheals (Hives) 0 = None 1 = 1–6 wheals 2 = 7–12 wheals 3 = >12 wheals	Itch Severity 0 = None 1 = Mild 2 = Moderate 3 = Severe	Daily UAS Score (Sum of Wheals + Itch) 0-6	Number of Wheals (Hives) 0 = None 1 = 1–6 wheals 2 = 7–12 wheals 3 = >12 wheals	Itch Severity 0 = None 1 = Mild 2 = Moderate 3 = Severe	Daily UAS Score (Sum of Wheals + Itch) 0-6
1	2	3	5	0	0	0
2	2	3	5	0	0	0
3	3	3	6	0	0	0
4	2	3	5	0	0	0
5	2	3	5	0	0	0
6	2	3	5	0	0	0
7	3	3	6	0	0	0

Financial support : NIL

Conflicting Interest: None

Dr Ojasvi Singla
G20, Ground Floor, Bakson Homoeopathic Medical College and Hospital, Knowledge Park-1, Greater Noida, Gautam Buddha Nagar, Uttar Pradesh 201310, India.
Email : ojasvisingla98@gmail.com