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 their minimal sedating effects. For severe or persistent cases, these can be taken up to four times the standard dose under medical supervision 1. First-generation antihistamines like diphenhydramine (25-50mg every 4-6 hours) may be used for nighttime relief due to their sedating properties.

Key Considerations

• Avoiding known triggers is essential, as is keeping the skin cool with cool compresses or cool showers to reduce itching.
• For acute severe hives, oral corticosteroids such as prednisone (40-60mg daily for 3-5 days) can provide short-term relief, though they're not recommended for long-term use due to side effects.
• For chronic urticaria lasting beyond six weeks, additional treatments may include omalizumab injections, cyclosporine, or leukotriene modifiers like montelukast.
• These medications work by blocking histamine receptors or reducing inflammation, as hives result from the release of histamine and other inflammatory chemicals from mast cells in the skin in response to triggers like allergens, medications, or physical stimuli 1.

Additional Guidance

• According to the most recent guidelines, antihistamines are the mainstay of therapy for urticaria, with over 40% of hospitalized patients showing a good response to them 1.
• The use of epinephrine is generally reserved for anaphylaxis, a more severe and life-threatening condition, and not typically used for the treatment of hives unless there are signs of anaphylaxis 1.
• It's crucial to differentiate between anaphylaxis and urticaria, as the treatment approaches differ significantly, with anaphylaxis requiring immediate administration of epinephrine 1.

From the FDA Drug Label

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. 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

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

• Key benefits of epinephrine include:
  • Relief of anaphylaxis symptoms
  • Alleviation of pruritus and urticaria
  • Relaxation of smooth muscle in the stomach, intestine, uterus, and urinary bladder
• Administration: intramuscular (IM) injection

From the Research

Treatment Options for Hives (Urticaria)

• The treatment for hives (urticaria) can vary depending on the severity and duration of the condition 3.
• For acute urticaria, treatment may involve antihistamines, such as diphenhydramine, and corticosteroids 4, 5.
• In some cases, H2-receptor antagonists, such as cimetidine and ranitidine, may be used in combination with antihistamines to improve symptoms 4, 6.
• A short course of oral prednisone may be effective in treating antihistamine-resistant chronic urticaria, with nearly 50% of patients experiencing remission 5.
• The treatment approach for urticaria typically follows a standardized algorithmic approach, with patients who do not respond to initial treatment being referred to a specialist for further evaluation and treatment 3.

Medications Used to Treat Hives

• Antihistamines, such as diphenhydramine, are commonly used to treat urticaria 4, 6.
• Corticosteroids, such as prednisone, may be used to treat antihistamine-resistant chronic urticaria 5.
• H2-receptor antagonists, such as cimetidine and ranitidine, may be used in combination with antihistamines to improve symptoms 4, 6.
• The use of H2-receptor antagonists in the treatment of urticaria is not universally accepted, and more research is needed to fully understand their effectiveness 6, 7.

Response to Treatment

• The response to treatment for urticaria can vary depending on the individual and the severity of the condition 5.
• Some patients may experience complete remission of symptoms, while others may experience only partial improvement 5.
• The prognosis and outcome of urticaria is generally very favorable for most patients, with the majority experiencing significant improvement or complete remission of symptoms 3.