Management Approach for Urticaria
The first-line treatment for urticaria is second-generation H1 antihistamines, which can be titrated up to 4 times the standard dose for inadequate symptom control. 1, 2
Classification and Diagnosis
Urticaria is classified based on clinical presentation:
Ordinary urticaria:
- Acute (≤6 weeks)
- Chronic (>6 weeks)
- Episodic (acute intermittent/recurrent)
Physical urticarias (triggered by specific physical stimuli):
- Mechanical (delayed pressure, dermographism, vibratory)
- Thermal (cholinergic, cold contact, heat)
- Other (aquagenic, solar, exercise-induced)
Angio-oedema without weals:
- Idiopathic
- Drug-induced (especially ACE inhibitors)
- C1 esterase inhibitor deficiency
Other types:
- Contact urticaria
- Urticarial vasculitis
- Autoinflammatory syndromes
Key diagnostic features include:
- Duration of individual weals: 2-24 hours in ordinary urticaria, <1 hour in most physical urticarias (except delayed pressure), and days in urticarial vasculitis 1
- Pattern of occurrence: spontaneous vs. induced by specific triggers
Treatment Algorithm
Step 1: First-Line Treatment
- Second-generation H1 antihistamines (cetirizine, loratadine, fexofenadine) at standard doses 1, 2, 3
- Preferred for minimal sedation and longer duration of action
- Example: Cetirizine 10mg daily or fexofenadine 180mg daily
Step 2: For Inadequate Control After 2-4 Weeks
- Increase second-generation H1 antihistamine dose up to 4× standard dose 2
- Example: Cetirizine 10mg QID or fexofenadine 180mg QID
Step 3: For Refractory Cases
- Add omalizumab 300mg subcutaneously every 4 weeks 2, 4, 5
- FDA-approved for chronic spontaneous urticaria in patients ≥12 years
- Particularly effective for patients with autoimmune urticaria
- Allow up to 6 months to assess full response
Step 4: For Severe Refractory Cases
- Consider cyclosporine (off-label) 5
- Effective in 54-73% of patients, especially those with autoimmune urticaria
- Monitor for adverse effects including kidney dysfunction and hypertension
For Acute Severe Flares
- Short course of oral corticosteroids 2
- Prednisone 0.5-1 mg/kg/day (typically 30-60mg daily)
- Continue until significant improvement (usually 3-7 days)
- Avoid long-term use due to side effects
Special Considerations
Physical Urticarias
- Identify and avoid triggers where possible 1, 2
- For cholinergic urticaria:
- Avoid overheating, strenuous activity, emotional stress, hot baths/showers
- Consider cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) 2
Angio-oedema
- Rule out C1 esterase inhibitor deficiency if recurrent angio-oedema without weals 1
- Discontinue ACE inhibitors if suspected as cause 1
- Epinephrine for severe angio-oedema with respiratory/cardiovascular involvement 2
Adjunctive Treatments
- H2 antihistamines (ranitidine, cimetidine) in combination with H1 antihistamines 1, 3
- Leukotriene receptor antagonists (montelukast) 1, 3
- First-generation H1 antihistamines at bedtime for nocturnal symptoms 1, 3
- Avoid in elderly due to increased fall risk and cognitive impairment 2
Prognosis
- More than 50% of patients with chronic urticaria will have resolution or improvement within one year 3, 6
- Patients with both weals and angio-oedema tend to have a poorer prognosis, with >50% still having active disease after 5 years 1
Common Pitfalls to Avoid
Excessive laboratory testing in chronic urticaria - limit workup unless history or exam suggests specific underlying conditions 3, 6
Long-term corticosteroid use - restrict to short courses for severe acute urticaria or angio-oedema affecting the mouth 1, 2
Overlooking autoimmune causes - approximately 30% of chronic urticaria cases have an autoimmune etiology 1, 7
Inadequate antihistamine dosing - many patients require higher than standard doses for symptom control 1, 2, 5
Failure to identify physical triggers in inducible urticarias, which can be managed through avoidance strategies 1, 2