What is the recommended dose of prednisone (corticosteroid) for treating urticaria (hives)?

Prednisone Dosing for Urticaria

For acute urticaria, prednisone 50 mg daily for 3 days is recommended, although lower doses are often effective. 1

Acute vs. Chronic Urticaria Treatment Algorithm

Acute Urticaria

1. First-line: H1 antihistamines

   • Second-generation preferred (cetirizine 10mg, loratadine 10mg, fexofenadine 180mg daily)

2. For severe or refractory cases:

   • Prednisone 50mg daily for 3 days 1
   • Lower doses (20mg twice daily for 4 days) can also be effective 2
   • Improvement is typically seen as early as the day after the first dose 3

Chronic Urticaria

1. First-line: Second-generation H1 antihistamines at standard doses

   • If inadequate control after 2-4 weeks, increase dose up to 4x standard dose 4

2. For antihistamine-resistant cases:

   • Short tapering course of oral prednisone over 3-4 weeks 1
   • Starting dose: 25mg/day for 3 days 3
   • Typical effective dose: 40mg prednisone daily 5
   • Goal: Quickly reach an effective low, alternate-day dose followed by discontinuation 5

3. For long-term management:

   • Long-term oral corticosteroids should not be used in chronic urticaria except in very selected cases under specialist supervision 1

Evidence Quality and Considerations

The recommendation for prednisone 50mg daily for 3 days in acute urticaria comes from the British Journal of Dermatology guidelines 1, which provides the highest level of evidence among the sources. Research supports that a short course of prednisone can be highly effective, with one study showing nearly 50% of patients with antihistamine-resistant chronic urticaria achieving remission after a single short course 3.

A randomized controlled trial demonstrated that adding prednisone (20mg twice daily for 4 days) to antihistamine therapy significantly improved both symptomatic and clinical response in acute urticaria, with patients showing faster and more complete improvement without apparent adverse effects 2.

Important Caveats and Pitfalls

• Avoid long-term corticosteroid use for chronic urticaria due to potential adverse effects 1, 4
• Do not rely solely on corticosteroids for anaphylaxis or severe angioedema with respiratory/cardiovascular involvement - epinephrine is first-line therapy in these cases 4
• Monitor for steroid side effects including hyperglycemia, hypertension, mood changes, and insomnia
• Taper appropriately after achieving control to minimize risk of rebound symptoms
• Consider underlying causes of urticaria before initiating treatment, as some forms may require specific management approaches

For urticarial vasculitis and severe delayed pressure urticaria, longer tapering courses of oral steroids over 3-4 weeks may be necessary 1, but these are specific subtypes requiring specialist evaluation.