What is the treatment for urticaria multiforme?

Treatment of Urticaria Multiforme

H1 antihistamines are the first-line treatment for urticaria multiforme, with nonsedating options like cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine being the preferred initial therapy. 1

First-line Treatment Approach

Antihistamines

• Nonsedating H1 antihistamines:

  • Start with standard doses of cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine once daily
  • If response is inadequate, increase the dose above the manufacturer's licensed recommendation when potential benefits outweigh risks 1
  • Offer patients at least two different nonsedating H1 antihistamines to try, as individual responses vary 1

• For nighttime symptoms:

  • Consider sedating antihistamines if symptoms disrupt sleep
  • Low-dose doxepin can be effective, especially if associated depression is present 2

General Measures

• Identify and minimize aggravating factors:
  • Avoid overheating, stress, and alcohol
  • Discontinue medications that may worsen urticaria (aspirin, NSAIDs, codeine)
  • Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 1

Second-line Treatment Options

When H1 Antihistamines Are Insufficient

• Add H2 receptor antagonists:

  • Can be combined with H1 antihistamines for enhanced effect 1, 2
  • Help prevent histamine-mediated acid secretion and blunt vasoactive effects 1
  • Note: H1 and H2 blockers with anticholinergic effects may cause cognitive decline, especially in elderly patients 1

• Consider leukotriene receptor antagonists:

  • Montelukast or zafirlukast may be beneficial, especially for dermatologic symptoms 1
  • Work best in conjunction with H1 antihistamines 1

For Severe or Refractory Cases

• Short courses of oral corticosteroids:

  • Effective for crisis management but should be tapered quickly to limit adverse effects 1
  • Reserve for severe cases unresponsive to antihistamines 2

• Oral cromolyn:

  • Particularly helpful for gastrointestinal symptoms 1
  • Start at lowest dose and gradually increase to 200 mg 4 times daily (before meals and at bedtime)
  • Requires at least 1 month trial to determine efficacy 1

Special Considerations

Pediatric Patients

• Treatment approach is similar to adults, but dosing should be adjusted for age and weight 3
• Acute episodic form is most common in children, often triggered by viruses, allergies, or physical stimuli 3

Monitoring and Follow-up

• Evaluate response to treatment within 2-4 weeks
• If no improvement, consider increasing antihistamine dose or adding second-line agents
• Reassure patients that prognosis for eventual recovery is excellent, though some cases may be persistent 1

Common Pitfalls to Avoid

• Overuse of systemic corticosteroids: Limit to short courses for severe flares
• Inadequate antihistamine dosing: Many patients require higher than standard doses
• Failure to identify triggers: Carefully assess for physical stimuli, medications, or foods that may exacerbate symptoms
• Ignoring comorbidities: Consider screening for thyroid autoimmunity in chronic cases 1
• Excessive laboratory testing: The diagnosis is primarily clinical, and investigations should be guided by history rather than performed routinely 1

Remember that urticaria has a capricious course and may resolve spontaneously. About 50% of patients are free of lesions within 1 year, though 20% may continue to have episodes for more than 20 years 4.