Diet and Chronic Urticaria: Dietary Modification as a Treatment Strategy

Patients with chronic urticaria (CU) often ask about dietary modification. Research has indicated that specific dietary changes may be helpful in a subset of patients. Immunological food reactions are rare, but potential triggers of CU include those seen in certain settings, as in patients with a history of tick bites, a history of raw or marinated fish ingestion, or those with celiac disease. Nonimmunological food intolerances may also contribute, although mechanism of action is not well understood. Trials of pseudoallergen-free diets and low-histamine diets have resulted in partial remission in a subset of patients, while oral provocation testing has confirmed that some patients experience worsening of symptoms after ingestion of food additives, tomatoes, herbs, seafood, alcohol, and other foods. An increased prevalence of vitamin D deficiency has also been noted in patients with CU compared with healthy controls. While oral antihistamines remain the mainstay of therapy in CU, education on potential dietary factors may be offered to a selection of the group of patients. For those at risk or reporting symptoms suggestive of celiac disease, vitamin D deficiency, delayed reactions to mammalian meat, or exposure to raw fish, further workup is recommended. While education on dietary modification may be offered to other patients, this approach may benefit only a subset, and no test is available to identify these patients. A minimum of 3 weeks may be needed to determine response, and only specific diets that have been systematically studied should be considered. Any elimination diet should be used with caution because of the potential for nutritional deficiencies.