What is the treatment for hives (urticaria)?

From the Guidelines

The treatment for hives (urticaria) typically begins with oral antihistamines, with second-generation options like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) preferred due to less sedation. For severe or persistent cases, higher doses may be needed, or first-generation antihistamines like diphenhydramine (25-50mg every 4-6 hours) can be added, particularly at night. Avoiding triggers is essential, so patients should track potential causes such as certain foods, medications, heat, cold, pressure, or stress. For immediate relief, cool compresses and loose clothing can help reduce itching and discomfort. In severe cases that don't respond to antihistamines, short courses of oral corticosteroids like prednisone (20-40mg daily for 3-5 days) may be prescribed. For chronic urticaria lasting more than six weeks, additional treatments might include leukotriene modifiers like montelukast (10mg daily), H2 antihistamines such as famotidine (20mg twice daily), or in refractory cases, omalizumab injections 1. Antihistamines work by blocking histamine receptors, reducing the inflammatory response that causes the characteristic itchy welts. Patients should seek emergency care if hives are accompanied by difficulty breathing, swelling of the face or throat, or dizziness, as these may indicate anaphylaxis.

Some key points to consider in the management of urticaria include:

• The use of antihistamines as the first-line treatment for urticaria, with second-generation options preferred due to less sedation 2
• The importance of avoiding triggers and tracking potential causes of urticaria 3
• The use of cool compresses and loose clothing for immediate relief of itching and discomfort 4
• The consideration of short courses of oral corticosteroids for severe cases that don't respond to antihistamines 5
• The potential use of leukotriene modifiers, H2 antihistamines, or omalizumab injections for chronic urticaria lasting more than six weeks 1

It's also important to note that patients with urticaria should be evaluated for potential underlying causes, such as autoimmune disorders or allergies, and that referral to a specialist may be necessary in some cases 3. Additionally, patients should be educated on the proper use of antihistamines and other medications, as well as the importance of seeking emergency care if symptoms worsen or if anaphylaxis is suspected 6.

From the FDA Drug Label

XOLAIR is indicated for the treatment of adults and adolescents 12 years of age and older with chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment.

The recommended dosage for chronic spontaneous urticaria is not dependent on serum IgE level or body weight.

The treatment for hives (urticaria), specifically chronic spontaneous urticaria (CSU), is XOLAIR (omalizumab) for adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment 7.

• Key points:
  • XOLAIR is used for CSU that is not controlled with H1 antihistamines.
  • The dosage of XOLAIR for CSU does not depend on serum IgE level or body weight.
  • XOLAIR is not indicated for the treatment of other forms of urticaria.

From the Research

Treatment Options for Hives (Urticaria)

• The primary treatment for hives includes antihistamines, omalizumab, and cyclosporine, with success rates of 40-55%, 65-80%, and 70-80%, respectively 8.
• The use of antihistamines in high dosage (at least four times a day) is effective in close to half the patients with chronic spontaneous urticaria (CSU) 8.
• For antihistamine resistance, the use of omalizumab has revolutionized therapy of antihistamine-resistant cases because of its efficacy and excellent side-effect profile 8.
• If the response is insufficient, cyclosporine is the next choice, but patients should be monitored regarding any adverse effects on blood pressure or renal function 8.

Alternative Treatment Options

• H1 antihistamines and, sometimes, short-term systemic corticosteroids are preferred for the treatment of urticaria, with H2 antagonists added during resistant cases 9.
• Other treatment options, such as omalizumab, cyclosporine, and leukotriene receptor antagonists, may be considered during missed events 9.
• Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile 10.
• Loratadine, a second-generation antihistamine, may be distinguished from other second-generation antihistamines by its pharmacodynamic profile, as well as its tolerability and safety 11.

Treatment Approach

• Treatment follows a standardized algorithmic approach as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines 12.
• Patients not responsive to steps 1 or 2 should be referred to an urticaria specialist for further evaluation and treatment 12.
• The prognosis and outcome of urticaria is generally very favorable for most patients 12.