What is the treatment for whole body hives (urticaria)?

From the Guidelines

The treatment for whole body hives (urticaria) typically begins with non-sedating antihistamines such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) 1. For severe cases, dosing can be increased up to four times the standard dose under medical supervision. If symptoms persist, adding an H2 blocker like famotidine (20mg twice daily) may help, as evidenced by the potential benefits of combining H1 and H2 antihistamines in some patients 1. For acute severe outbreaks, a short course of oral corticosteroids such as prednisone (40-60mg daily for 3-5 days) might be prescribed, although this is typically reserved for more severe cases. Cold compresses and lukewarm baths with colloidal oatmeal can provide symptomatic relief. Avoiding triggers is essential, so keeping a diary to identify potential causes like certain foods, medications, or environmental factors is recommended. Wear loose-fitting cotton clothing to reduce skin irritation. If hives persist beyond six weeks, they're considered chronic urticaria, which may require additional treatments like omalizumab (Xolair) or cyclosporine. Antihistamines work by blocking histamine receptors, preventing the chemical mediator responsible for the itching, swelling, and redness associated with hives. 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
• The use of antihistamines above the manufacturers’ recommended dose, which may be considered in patients who do not respond to standard dosing 1
• The potential benefits and risks of combining H1 and H2 antihistamines, as well as the use of sedating antihistamines in certain cases 1 Seek immediate medical attention if hives are accompanied by difficulty breathing, swelling of the face or throat, or dizziness, as these may indicate anaphylaxis. It's also important to note that the efficacy and safety of antihistamines in urticaria is well-established, although not all patients respond and some may experience side effects 1. In terms of specific antihistamine options, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine are all currently licensed for urticaria in the U.K., with varying dosing schedules and potential side effects 1. Overall, the treatment of whole body hives (urticaria) should be individualized based on the severity of symptoms, potential triggers, and patient response to treatment, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Epinephrine 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 whole body hives (urticaria) is epinephrine (IM), which alleviates pruritus, urticaria, and angioedema 2 2.

• Key benefits of epinephrine (IM) include:
  • Relief of pruritus and urticaria
  • Relief of angioedema
  • Relief of gastrointestinal and genitourinary symptoms associated with anaphylaxis
• Administration: Epinephrine (IM) is administered intramuscularly.

From the Research

Treatment Options for Whole Body Hives (Urticaria)

• The primary treatment for urticaria involves the use of antihistamines, particularly H1-antihistamines, as they are effective in relieving symptoms such as itching and hives 3.
• Second-generation, non-sedating H1-receptor antihistamines are preferred over first-generation antihistamines due to their reduced side effects, such as sedation and anticholinergic effects 3.
• In some cases, the combination of H1 and H2 antihistamines may be beneficial, especially for certain types of urticaria, such as urticaria factitia 3.
• Systemic corticosteroids may be added to antihistamines in severe cases of acute urticaria, but their effectiveness is still unclear and requires further investigation 4.
• Other treatment options, such as ranitidine and cimetidine, have shown some efficacy in relieving symptoms of urticaria, but the evidence is limited and more research is needed 5.

Specific Treatment Approaches

• For chronic urticaria, antihistamines are the mainstay of treatment, with second-generation antihistamines being preferred due to their efficacy and safety profile 3, 6.
• In cases of acute urticaria, the combination of diphenhydramine and ranitidine or cimetidine may be effective in relieving symptoms, but more research is needed to confirm this 4.
• For physical urticaria, treatment options may vary depending on the specific type and triggers, and may involve a combination of antihistamines and other medications 6.

Important Considerations

• It is essential to identify and address any underlying triggers or causes of urticaria, such as allergies or infections, to develop an effective treatment plan 3, 6.
• Patients with urticaria should be monitored for any adverse effects of treatment, such as sedation or anticholinergic effects, and adjusted as needed 5, 3.