What is the treatment for hives (urticaria)?

Treatment for Hives (Urticaria)

Second-generation H1 antihistamines are the first-line treatment for hives (urticaria), with dosing that can be increased up to four times the standard dose if symptoms persist. 1

Step-by-Step Treatment Algorithm

First-Line Treatment:

• Start with a standard dose of a second-generation (non-sedating) H1 antihistamine such as:
  • Cetirizine 10 mg daily
  • Loratadine 10 mg daily
  • Fexofenadine 180 mg daily
  • Levocetirizine 5 mg daily
  • Desloratadine 5 mg daily

If inadequate control after 2-4 weeks (or earlier if symptoms are intolerable):

• Increase the dose of the second-generation H1 antihistamine up to 4× the standard dose 1, 2
  • For example: Cetirizine 20-40 mg daily or Fexofenadine up to 720 mg daily

If symptoms remain inadequately controlled:

• Add omalizumab as second-line therapy (300 mg subcutaneously every 4 weeks) 1
• If needed, the dose can be increased up to 600 mg every 2 weeks for patients with insufficient response 1
• Allow up to 6 months for patients to respond to omalizumab therapy

For refractory cases:

• Add cyclosporine (third-line therapy) at doses up to 5 mg/kg body weight 1
• Monitor blood pressure and renal function every 6 weeks during cyclosporine treatment

Special Considerations

For acute severe urticaria/angioedema:

• Epinephrine is first-line therapy for anaphylaxis or severe angioedema with respiratory/cardiovascular involvement 1
• Short courses of oral corticosteroids (e.g., prednisone) may be used for severe acute urticaria or angioedema affecting the mouth 1, 3
  • Typical dose: 40 mg prednisone daily with rapid taper 3
  • Long-term oral corticosteroids should be avoided for chronic urticaria 1

Adjunctive treatments:

• H2 antihistamines (e.g., ranitidine) may provide additional benefit when added to H1 antihistamines 1
• Sedating (first-generation) antihistamines may be added at night for patients with sleep disturbance 1
• Leukotriene receptor antagonists (e.g., montelukast) can be considered as add-on therapy 4, 5

Important Clinical Pearls

• Antihistamines should be used regularly, not just when hives appear 3
• The "as much as needed and as little as possible" approach should guide treatment, with step-down considered after 3 consecutive months of complete control 1
• When stepping down, reduce the antihistamine dose by no more than 1 tablet per month 1
• If control is lost during step-down, return to the last effective dose 1

Common Pitfalls to Avoid

1. Delaying epinephrine for anaphylaxis: Never withhold epinephrine for urticaria with systemic symptoms (hypotension, laryngeal edema, respiratory distress) 1

2. Relying solely on antihistamines for severe presentations: Antihistamines alone are insufficient for anaphylaxis or severe angioedema 1

3. Long-term corticosteroid use: Avoid prolonged corticosteroid treatment for chronic urticaria due to adverse effects 1

4. Inadequate dosing of antihistamines: Many patients require higher than standard doses for symptom control 2

5. Premature treatment changes: Allow sufficient time (2-4 weeks) to assess response before escalating therapy 1

Research shows that approximately 75% of patients with difficult-to-treat urticaria respond to higher than conventional antihistamine doses without increased somnolence or safety concerns 2. More than half of patients with chronic urticaria will experience resolution or significant improvement within one year 4, 5.