What is the treatment for urticaria?

From the Guidelines

The treatment for urticaria should start with non-sedating antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), with the option to increase dosing up to four times the standard dose for persistent symptoms, as recommended by the most recent guidelines 1.

First-Line Treatment

• Non-sedating antihistamines are the first line of treatment for urticaria, with options including cetirizine, loratadine, and fexofenadine.
• These medications can be taken once daily, with cetirizine having the shortest time to attain maximum concentration, which may be beneficial in cases where rapid relief is needed 1.

Second-Line Treatment

• For patients who do not respond to antihistamines, omalizumab injections may be considered, particularly for chronic urticaria lasting beyond 6 weeks 1.
• The recommended starting dose of omalizumab is 300 mg every 4 weeks, with the option to increase the dose or shorten the interval for patients with insufficient response.

Additional Therapies

• Short courses of oral corticosteroids, such as prednisone (20-40mg daily for 3-5 days), may be used for severe cases unresponsive to antihistamines 1.
• H2 blockers, such as famotidine (20mg twice daily), can be added for additional relief, particularly for patients with dyspepsia accompanying severe urticaria 1.

Management Approach

• The treatment approach should follow an "as much as needed and as little as possible" principle, with step-up and step-down strategies based on disease control assessed with the Urticaria Control Test (UCT) 1.
• Patients should be encouraged to maintain a symptom diary to track potential causes and identify triggers, and to avoid identified triggers as part of long-term management.

From the FDA Drug Label

Chronic Urticaria: Cetirizine Hydrochloride Oral Solution, USP is indicated for the treatment of the uncomplicated skin manifestations of chronic idiopathic urticaria in children 6 months to 5 years of age. It significantly reduces the occurrence, severity, and duration of hives and significantly reduces pruritus.

The treatment for urticaria is cetirizine.

• Key benefits: reduces the occurrence, severity, and duration of hives and pruritus.
• Target population: children 6 months to 5 years of age with chronic idiopathic urticaria. 2

From the Research

Treatment Options for Urticaria

• The primary treatment for urticaria involves the use of antihistamines, which should be taken on a regular basis, not just after hives occur 3.
• Second-generation, nonsedating antihistamines such as terfenadine, astemizole, loratadine, and cetirizine hydrochloride are preferred for daytime use due to their effectiveness and reduced central nervous system side effects 4, 5.
• If antihistamines fail to control symptoms, the addition of glucocorticosteroids can be tried for short periods, with most patients responding to doses equivalent to 40 mg of prednisone daily 3.
• For chronic spontaneous urticaria, treatment begins with antihistamines, and if high-dose antihistamines fail, omalizumab at 300 mg/month is the next step, effective in 70% of antihistamine-refractory patients 6.
• Cyclosporine is recommended for patients unresponsive to both antihistamines and omalizumab, effective in 65%-70% of patients, but requires careful monitoring of blood pressure and renal function 6.

Antihistamine Selection

• The choice of antihistamine depends on pharmacokinetic considerations and frequency of administration, with newer, nonsedating antihistamines such as loratadine or cetirizine being preferred for chronic idiopathic urticaria 5, 7.
• Older antihistamines like chlorpheniramine and hydroxyzine are effective but have marked sedative and anticholinergic effects, making them less desirable for long-term use 7.
• Second-generation antihistamines have reduced adverse effects and are preferred for their efficacy and safety profile 4, 7.

Additional Treatment Considerations

• Corticosteroids should not be used chronically due to cumulative toxicity but can be employed for brief courses (3-10 days) for severe exacerbations 6.
• Other agents like dapsone or sulfasalazine can be tried for patients unresponsive to antihistamines, omalizumab, and cyclosporine, although their effectiveness and safety profiles vary 6.