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, including identified foods, medications, or physical stimuli. For acute severe hives, oral corticosteroids like prednisone (40-60mg daily for 3-5 days) may provide relief, though they're not recommended for long-term use. Cool compresses and loose clothing can help reduce discomfort. For chronic urticaria lasting beyond 6 weeks, additional treatments might include H2 antihistamines like famotidine (20mg twice daily), leukotriene modifiers such as montelukast (10mg daily), or in refractory cases, omalizumab injections 1. Severe reactions with breathing difficulties or swelling of the face, lips, or throat require immediate emergency care as these may indicate anaphylaxis, and epinephrine injection is the preferred treatment in such cases 1. Antihistamines work by blocking histamine receptors, reducing the inflammatory response that causes the characteristic itchy welts of hives.

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

• The use of antihistamines as the mainstay of therapy, with second-generation options preferred due to less sedation 1.
• The importance of avoiding triggers, including identified foods, medications, or physical stimuli 1.
• The potential need for additional treatments, such as H2 antihistamines, leukotriene modifiers, or omalizumab injections, in cases of chronic urticaria 1.
• The need for immediate emergency care in cases of severe reactions with breathing difficulties or swelling of the face, lips, or throat, as these may indicate anaphylaxis 1.

It's also important to note that the treatment approach may vary depending on the specific presentation and severity of the urticaria, as well as the presence of any underlying conditions or triggers 1.

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 hives (urticaria) is epinephrine (IM), as it alleviates pruritus, urticaria, and angioedema 2 2.

• Key benefits of epinephrine include:
  • Relief of urticaria
  • Relief of pruritus
  • Relief of angioedema
• Administration: Epinephrine is administered intramuscularly for emergency treatment of allergic reactions (Type I), including anaphylaxis.

From the Research

Treatment for Hives (Urticaria)

The treatment for hives (urticaria) typically involves a stepwise approach, with the goal of relieving symptoms and preventing future episodes.

• The first line of therapy for urticaria is second-generation H1 antihistamines 3.
• In cases where antihistamines are not effective, other treatment options may be considered, such as:
  • Leukotriene receptor antagonists 4, 5
  • Systemic corticosteroids 5
  • Anti-inflammatory drugs (e.g. dapsone, sulfasalazine, hydroxychloroquine) 5
  • Immunosuppressive drugs (e.g. cyclosporine, methotrexate, omalizumab) 4, 5
• For chronic urticaria that is refractory to antihistamines, alternative therapeutic approaches may be considered, including:
  • Increasing the daily dosage of antihistamines up to fourfold 5
  • Adding other medications, such as omalizumab or other biologic drugs 5
• In children, the treatment for urticaria may involve identification and removal of triggering agents, reduction of non-specific factors that may contribute to urticaria, and use of anti-H1 antihistamines (and/or steroids for short periods if antihistamines are not effective) 6.
• In some cases, cyclosporine and tacrolimus may be used to treat chronic urticaria that is resistant to other treatments 6.