From the Guidelines
Papular urticaria is best treated with a combination of avoiding the insect causing the bites, topical treatments, and oral medications for symptom relief, with the most recent guidelines suggesting an "as much as needed and as little as possible" approach to pharmacologic treatment 1. To manage papular urticaria, it is essential to identify and eliminate the source of bites by:
- Washing bedding in hot water
- Vacuuming frequently
- Using insect repellents containing DEET or permethrin on clothing and furniture For immediate symptom relief, apply:
- Topical corticosteroids like hydrocortisone 1% cream 2-3 times daily for 5-7 days to reduce inflammation and itching
- Topical antihistamines such as diphenhydramine, though they may cause sensitization For more severe cases, oral antihistamines like:
- Cetirizine 10mg daily
- Diphenhydramine 25-50mg every 6 hours can effectively control itching Antibiotics may be necessary if secondary bacterial infection develops, indicated by increased redness, warmth, or pus. Cool compresses and calamine lotion can provide additional relief. Treatment typically continues until the lesions resolve, usually within 1-2 weeks. The use of omalizumab, an anti-IgE antibody, has been shown to be effective in treating chronic spontaneous urticaria, and its use is recommended in the latest guidelines 1. It is crucial to note that the treatment approach should be individualized, and the patient's response to treatment should be closely monitored, with adjustments made as needed to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema psoriasis poison ivy, oak, sumac insect bites detergents jewelry cosmetics soaps seborrheic dermatitis Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily
- Papular urticaria is caused by insect bites, which is listed as one of the conditions that hydrocortisone (TOP) can temporarily relieve itching associated with.
- The treatment for papular urticaria using hydrocortisone (TOP) would be to apply to the affected area not more than 3 to 4 times daily for adults and children 2 years of age and older 2 2.
From the Research
Treatment Options for Papular Urticaria
- The mainstay of treatment for urticaria, including papular urticaria, is avoidance of triggers, although these can be identified in only 10 to 20 percent of patients with chronic urticaria 3, 4.
- First-line pharmacotherapy for acute and chronic urticaria is nonsedating second-generation antihistamines (histamine H1 blockers), which can be titrated to larger than standard doses 3, 4, 5.
- Other treatment options include:
- First-generation antihistamines 3, 4, 6
- Histamine H2 blockers 3, 4, 7
- Leukotriene receptor antagonists 3, 4, 5
- Brief corticosteroid bursts 3, 4, 7
- Omalizumab, a humanized monoclonal anti-immunoglobulin E, for chronic urticaria that is unresponsive to H1 antagonists 5
- Cyclosporine, for refractory chronic urticaria 4, 5
Special Considerations
- In some cases, the combination of an antihistamine and an H2 antagonist may be effective, such as for symptomatic dermatographism 6.
- For patients with refractory chronic urticaria, referral to subspecialists for additional treatments may be necessary 4.
- It is essential to rule out anaphylaxis and consider specific underlying conditions that may be contributing to the urticaria 3, 4, 7.