What is the treatment for urticaria?

From the Guidelines

The treatment for urticaria (hives) focuses on symptom relief and identifying triggers, with first-line treatment including non-sedating antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) 1. For persistent symptoms, dosing can be increased up to four times the standard dose. Some key points to consider in the treatment of urticaria include:

• Identifying and avoiding triggers is crucial in managing urticaria
• Keeping a symptom diary can help identify potential triggers
• Antihistamines work best when taken regularly rather than as needed
• For severe or unresponsive cases, adding H2 blockers like ranitidine (150mg twice daily) or famotidine (20mg twice daily) may help
• Acute severe urticaria may require short courses of oral corticosteroids like prednisone (40-60mg daily for 3-5 days)
• For chronic urticaria resistant to antihistamines, omalizumab injections (150-300mg every 4 weeks) or immunosuppressants like cyclosporine may be considered, as recommended in the latest guidelines 1. It's also important to note that antihistamines and glucocorticoids should not be used as a replacement for epinephrine in the treatment of anaphylaxis, but rather as adjunctive therapy 1. In terms of specific treatment regimens, the latest guidelines recommend a stepped approach, with increasing doses of antihistamines and the addition of other medications as needed, and also recommend a treatment duration of at least 3 consecutive months of complete control before stepping down the treatment 1. Overall, the goal of treatment is to provide symptom relief, identify and avoid triggers, and prevent future episodes of urticaria.

From the FDA Drug Label

Epinephrine also alleviates pruritus, urticaria, and angioedema and may relieve gastrointestinal and genitourinary symptoms associated with anaphylaxis because of its relaxer effects on the smooth muscle of the stomach, intestine, uterus and urinary bladder Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis. The signs and symptoms associated with anaphylaxis include flushing, apprehension, syncope, tachycardia, thready or unobtainable pulse associated with hypotension, convulsions, vomiting, diarrhea and abdominal cramps, involuntary voiding, airway swelling, laryngospasm, bronchospasm, pruritus, urticaria or angioedema, swelling of the eyelids, lips, and tongue.

The treatment for urticaria is epinephrine (IM), as it alleviates pruritus, urticaria, and angioedema 2 2.

• Key benefits of epinephrine (IM) include:
  • Alleviates pruritus, urticaria, and angioedema
  • Relieves gastrointestinal and genitourinary symptoms associated with anaphylaxis
  • Emergency treatment of allergic reactions (Type I), including anaphylaxis
• Administration: intramuscular and subcutaneous use.

From the Research

Treatment Options for Urticaria

The treatment for urticaria typically involves a combination of avoiding triggers, pharmacotherapy, and other measures to manage symptoms.

• Avoidance of triggers is the mainstay of treatment, if identified 3.
• The first-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses 3, 4.
• Other treatment options include:
  • First-generation H1 antihistamines
  • H2 antihistamines
  • Leukotriene receptor antagonists
  • High-potency antihistamines
  • Brief corticosteroid bursts 3
• In refractory chronic urticaria, patients can be referred to subspecialists for additional treatments, such as omalizumab or cyclosporine 3, 5.

Pharmacological Treatment

Pharmacological treatment for urticaria includes:

• Non-sedating second-generation antihistamines, such as cetirizine and rupatadine, which are effective in reducing symptoms of urticaria 6, 7.
• Intravenous cetirizine has been shown to be effective in treating acute urticaria, with benefits of less sedation and fewer adverse events compared to intravenous diphenhydramine 6.
• Rupatadine has been shown to be more effective than cetirizine in reducing symptoms of chronic spontaneous urticaria 7.

Non-Pharmacological Measures

Non-pharmacological measures to minimize hyper-responsive skin are also important and recommended, such as:

• Prevention of skin drying
• Avoidance of hot showers
• Avoidance of scrubbing
• Avoidance of excessive sun exposure 5.