How do you manage recurrent urticarial lesions in a patient with underlying connective tissue disease that is otherwise well-controlled?

Similar to other cases of chronic urticaria - skin-directed therapy with TCS + high dose daily antihistamines (e.g. fexofenadine 180 mg bid + doxepin 10 mg qhs). Then in recalcitrant cases, you can use urticaria drugs (can go for dapsone, MTX or MMF if you want to also target underlying CTD or can g...

Regarding connective tissue diseases, I am most familiar with urticaria occurring as a lupus "non-specific cutaneous manifestation" in some of my systemic lupus erythematosus (SLE) patients.

I have generally seen SLE-associated urticaria respond to the treatment of their SLE (i.e. gets better when t...

You can supplement H1 blockers with H2 blockers (famotidine) and montelukast or zileuton. The latter is expensive and difficult to get covered but can be helpful in the small subset of patients whose urticaria flares with the addition of montelukast.