What is the diagnosis and treatment for spontaneous urticaria (hives)?

From the Guidelines

Spontaneous urticaria should be treated with second-generation H1 antihistamines, such as cetirizine or loratadine, at standard doses, and the dose can be increased up to four times if symptoms persist, as recommended by the most recent guidelines 1. The primary goal of treatment is to alleviate symptoms and improve quality of life.

Diagnosis and Treatment

• The diagnosis of spontaneous urticaria is based on the presence of itchy hives without an identifiable external trigger.
• 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.
• Second-generation H1 antihistamines, such as cetirizine or loratadine, are the first-line treatment, and the dose can be increased up to four times the standard dose if symptoms persist 1.
• If antihistamines alone are insufficient, add-on therapies may include omalizumab (300 mg subcutaneously every 4 weeks) for severe cases, with the option to updose to 600 mg every 14 days if needed 1.
• Cyclosporine can be considered for patients who do not respond to higher than standard doses of omalizumab, but its use requires careful monitoring of blood pressure and renal function 1.

Management

• Patients should be advised to avoid known triggers, such as hot showers, tight clothing, or stress.
• Cool compresses and wearing loose, breathable clothing can help alleviate symptoms.
• The condition is caused by mast cell degranulation, releasing histamine and other inflammatory mediators, and antihistamines work by blocking histamine receptors, while omalizumab targets IgE antibodies involved in the allergic response.
• Most cases of spontaneous urticaria resolve within 6-12 weeks, but some may persist longer, requiring ongoing management.

Key Considerations

• The treatment approach should be individualized, taking into account the patient's response to treatment and potential side effects.
• Regular monitoring of disease control and adjustment of treatment as needed is crucial to achieve optimal outcomes.
• The use of sedating antihistamines as monotherapy is now less common due to concerns about reduced concentration and performance, but they can be effective and well-tolerated by some individuals 1.

From the Research

Diagnosis of Spontaneous Urticaria

• Spontaneous urticaria is defined as persistent symptoms of urticaria for 6 weeks or more 2
• It is associated with autoimmunity in approximately 45 percent of patients 2

Treatment of Spontaneous Urticaria

• First-line management is with H1-antihistamines, with second-generation non-sedating antihistamines preferred over first-generation sedating antihistamines 3, 4
• The dose of antihistamines may need to be increased up to 4 times the standard dose to achieve adequate symptom control 2, 5, 4
• If antihistamines are not effective, other treatment options include:
  • Omalizumab, which is effective in 70% of antihistamine-refractory patients 5, 6
  • Cyclosporine, which is effective in 65-70% of patients, but requires monitoring for side effects such as blood pressure and renal function changes 5, 6
  • Corticosteroids, which can be used for short-term relief of severe symptoms, but should not be used chronically due to toxicity 5, 6
• Other agents, such as dapsone, sulfasalazine, and leukotriene antagonists, may be tried in patients who are unresponsive to antihistamines and other treatments, but their efficacy is limited 2, 5, 6

Patient Perspective on Treatment

• Patients report that second-generation antihistamines are more effective and have fewer side effects than first-generation antihistamines 4
• Patients also report that up-dosing with antihistamines can provide significant added benefit, with 40-54% of patients reporting improvement with doses of 2-4 tablets daily 4