From the Guidelines
The best treatment for hives (urticaria) typically begins with non-sedating antihistamines like cetirizine (Zyrtec) 10mg, loratadine (Claritin) 10mg, or fexofenadine (Allegra) 180mg taken once daily, with the option to increase dosing up to four times the standard dose under medical supervision, as recommended by the latest guidelines 1. The treatment approach should follow an “as much as needed and as little as possible” principle, stepping up or down the treatment based on disease control assessed with the Urticaria Control Test (UCT) 1. Some key points to consider in the management of urticaria include:
- Identifying and avoiding known triggers such as certain foods, medications, heat, stress, or pressure on the skin 1
- Using cold compresses to reduce itching and swelling, and wearing loose-fitting clothing to prevent additional skin irritation
- Considering second-line treatments like omalizumab (Xolair) injections or immunosuppressants for chronic cases lasting more than six weeks 1
- Monitoring patients on cyclosporine for potential risks such as hypertension, epilepsy, hirsutism, gum hypertrophy, and renal failure, and adjusting treatment accordingly 1
- Seeking emergency medical attention if hives are accompanied by difficulty breathing, swelling of the face or throat, or dizziness, as these may indicate a severe allergic reaction requiring immediate treatment. In patients with insufficient response to antihistamines, omalizumab can be started at a dose of 300 mg every 4 weeks, with the option to updose if needed, based on well-designed robust double-blind placebo-controlled studies demonstrating its efficacy in chronic spontaneous urticaria (CSU) 1.
From the Research
Treatment Options for Hives
- The mainstay of treatment is avoidance of triggers, if identified 2
- First-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses 2
- First-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, high-potency antihistamines, and brief corticosteroid bursts may be used as adjunctive treatment 2
- For patients not responsive to initial treatment, referral to an urticaria specialist for further evaluation and treatment is recommended 3
Alternative Treatment Options
- Leukotriene receptor antagonists, such as montelukast, may be effective for certain cases of urticaria, particularly for patients who are not sufficiently controlled with histamine H(1)-receptor antagonists 4
- The biologic modifier, omalizumab, has been shown to reduce lesions of chronic urticaria within 1-2 weeks 5
- Cyclosporine may be considered for patients with refractory chronic urticaria 6, 2
Treatment Considerations
- The prognosis and outcome of urticaria is generally very favorable for most patients 3
- More than one-half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 2
- Patients with chronic idiopathic urticaria who are younger and have a shorter duration of illness may be more likely to respond to treatment with montelukast 4