What is the treatment for hives (urticaria)?

From the Guidelines

The treatment for hives (urticaria) typically begins with oral antihistamines, with second-generation non-sedating options like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) being first-line choices, as recommended by the most recent guidelines 1. For severe or persistent cases, these can be taken up to four times the standard dose under medical supervision. First-generation antihistamines like diphenhydramine (25-50mg every 4-6 hours) may be used for nighttime relief due to their sedating effects. For acute severe hives, oral corticosteroids such as prednisone (40-60mg daily for 3-5 days) might be prescribed for short-term use. Avoiding known triggers is essential, as is keeping the skin cool since heat can worsen symptoms. Some key points to consider in the management of urticaria include:

• The use of investigations above the minimum standard for the different clinical presentations of urticaria 1.
• Use of antihistamines above the manufacturers’ recommended dose 1.
• The role of antihistamines and glucocorticoids in the treatment of anaphylaxis, with antihistamines being used as adjunctive therapy and glucocorticoids having a limited role in the acute management of anaphylaxis 1.
• The importance of identifying and avoiding triggers, as well as the use of medications such as antihistamines and corticosteroids to manage symptoms 1. For chronic urticaria lasting more than six weeks, additional treatments may include leukotriene modifiers like montelukast, anti-inflammatory medications, or in refractory cases, biologics such as omalizumab, with the latest guidelines recommending an "as much as needed and as little as possible" approach to treatment 1. Antihistamines work by blocking histamine receptors, reducing the inflammatory response that causes the characteristic itchy welts. Cold compresses can provide immediate relief by constricting blood vessels and reducing inflammation, while loose cotton clothing helps prevent further irritation of affected skin. In cases where urticaria is suspected to be part of a more complex condition, such as anaphylaxis or systemic mastocytosis, referral to a specialist such as an allergist-immunologist may be necessary for further evaluation and management 1.

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.

XOLAIR should not be used for the emergency treatment of any allergic reactions, including anaphylaxis. XOLAIR should also not be used to treat other forms of hives, or sudden breathing problems.

In people with chronic hives, a blood test is not necessary to determine the dose or dosing frequency

The treatment for hives (urticaria) is omalizumab (XOLAIR) for adults and adolescents 12 years of age and older with chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment 2, 2, 2.

• Key points:
  • XOLAIR is not for emergency treatment of allergic reactions
  • XOLAIR is not for other forms of hives or sudden breathing problems
  • No blood test is needed to determine the dose for chronic hives treatment

From the Research

Treatment Options for Hives (Urticaria)

• The primary treatment for hives includes antihistamines, with a success rate of 40-55% 3
• Omalizumab is also effective, with a success rate of 65-80%, and is often used for antihistamine-resistant cases 3
• Cyclosporine can be used as an alternative, with a success rate of 70-80%, but patients should be monitored for adverse effects on blood pressure or renal function 3
• H1 antihistamines and short-term systemic corticosteroids are also preferred for treatment, with H2 antagonists added in resistant cases 4
• Other treatment options include leukotriene receptor antagonists, which may be considered for missed events 4

Antihistamines in Urticaria Treatment

• Antihistamines are the mainstay of treatment for urticaria, with newer nonsedating antihistamines having reduced adverse effects 5
• Loratadine or cetirizine, and possibly mizolastine, appear to be treatments of choice for chronic idiopathic urticaria 5
• A network meta-analysis found that olopatadine, fexofenadine, bilastine, rupatadine, and levocetirizine were more efficacious than placebo in reducing total symptom score (TSS) in chronic spontaneous urticaria (CSU) 6

Treatment Approach

• Treatment follows a standardized algorithmic approach, as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines 7
• Patients not responsive to initial treatment should be referred to an urticaria specialist for further evaluation and treatment 7
• The prognosis and outcome of urticaria is generally very favorable for most patients, with over 90% of patients able to be successfully treated with a combination of medications 3