Treatment of Cough with Shortness of Breath and Itchy Plaques

Rationale for Combined Approach

The American Thoracic Society suggests that patients presenting with cough, shortness of breath, and itchy plaques on the chest should be treated with an inhaled corticosteroid combined with an inhaled bronchodilator as first-line therapy, while simultaneously treating the dermatologic manifestation with an oral first-generation antihistamine/decongestant, addressing both the likely respiratory component and the allergic/dermatologic component concurrently 1, 2.
The presence of cough with shortness of breath in a patient with normal vitals suggests either cough variant asthma or nonasthmatic eosinophilic bronchitis, both of which respond to inhaled corticosteroids, as recommended by the American College of Chest Physicians 3, 2.

The American Academy of Allergy, Asthma, and Immunology recommends using oral first-generation antihistamine/decongestant for the itchy plaques, as first-generation antihistamines are effective for allergic manifestations 2, 4.
First-generation antihistamines have proven benefit for acute allergic symptoms, unlike newer non-sedating antihistamines which are ineffective for acute presentations, according to the American College of Allergy, Asthma, and Immunology 4.

The American College of Chest Physicians recommends that oral corticosteroids should be reserved for severe or refractory cases that fail to respond to inhaled corticosteroids and bronchodilators 2, 3.
Systemic corticosteroids carry significant side effects and should only be used after excluding poor compliance or other contributing conditions, as suggested by the American Thoracic Society 2.

The American College of Chest Physicians recommends a treatment algorithm starting with inhaled corticosteroid and inhaled bronchodilator, with oral diphenhydramine for itchy plaques, and reassessing for poor compliance or alternative diagnoses if no improvement occurs within 2 weeks 1, 2, 3, 4.

The American Academy of Allergy, Asthma, and Immunology advises against using newer non-sedating antihistamines for acute allergic symptoms as they are ineffective 4.
The American College of Chest Physicians recommends not jumping directly to oral steroids without first trying inhaled corticosteroids, as the patient's normal vitals indicate this is not a severe presentation 2, 1.

The itchy plaques should improve within days with first-generation antihistamines, as suggested by the American College of Allergy, Asthma, and Immunology 4.
If no improvement occurs within 2 weeks, reassess for alternative diagnoses or poor compliance before escalating therapy, according to the American Thoracic Society and the American College of Chest Physicians 2, 3.