What is the next step in managing urticaria in a patient who has already received oral steroids (e.g. prednisone) and still has symptoms?

Management of Persistent Urticaria After Oral Steroids

For patients with urticaria that persists despite oral steroid treatment, the next step should be adding a second-generation H1 antihistamine such as cetirizine or loratadine, potentially at higher than standard doses if needed. 1

Step-by-Step Management Algorithm

First-line approach after failed steroid therapy:

1. Add a second-generation H1 antihistamine

   • Options: Cetirizine 10mg daily, loratadine 10mg daily 1
   • Less sedating than first-generation antihistamines
   • Can be used regularly, not just when symptoms appear

2. If inadequate response to standard antihistamine dose:

   • Increase antihistamine dose (up to 4× standard dose may be needed) 1
   • Consider once-daily dosing for better compliance

3. If still inadequate control:

   • Add a second different H1 antihistamine 1
   • Consider adding an H2 antihistamine (though evidence for this combination is limited)

Second-line options if antihistamines fail:

• Leukotriene receptor antagonist (e.g., montelukast) 1
• Referral to dermatology for consideration of:
  • Immunomodulatory therapy
  • Cyclosporine (effective in about two-thirds of patients with severe autoimmune urticaria) 1
  • Mycophenolate mofetil (for steroid/antihistamine-resistant cases) 2

Important Clinical Considerations

Avoid common pitfalls:

• Prolonged oral corticosteroid use - should be limited to short courses only 1, 3

  • Long-term steroids may actually interfere with antihistamine efficacy 3
  • Risk of significant adverse effects with prolonged use 1

• First-generation antihistamines (e.g., diphenhydramine)

  • Can cause sedation and anticholinergic effects
  • May worsen hypotension in severe reactions 1

Special situations:

• For urticarial vasculitis or delayed pressure urticaria: These may require different management approaches, including longer steroid courses 1, 4

• For severe/refractory cases: Consider immunosuppressive therapy under specialist supervision 1

Evidence Quality Assessment

The evidence strongly supports antihistamines as the mainstay of treatment for urticaria that persists after steroid therapy. Guidelines consistently recommend against long-term oral corticosteroids for chronic urticaria 1, 3. While short courses of steroids may be useful for acute exacerbations 5, they should not be used for maintenance therapy.

Research shows that nearly 50% of patients with antihistamine-resistant urticaria can achieve remission after a short course of prednisone 5, but for those who don't respond, moving to antihistamines (particularly second-generation) is the recommended next step rather than continuing steroids 1.

For patients with truly refractory disease, immunomodulatory therapies under specialist supervision may be necessary 1, 2.