What is the approach for managing urticaria?

Management of Urticaria

Second-generation H1 antihistamines are the first-line treatment for urticaria, with doses that can be increased up to 4 times the standard dose for inadequate symptom control. 1

Classification and Diagnosis

Urticaria can be classified into:

• Ordinary urticaria: Weals last 2-24 hours
• Physical urticarias: Weals last less than 1 hour
• Angioedema without weals
• Other types: Contact urticaria, urticarial vasculitis, autoinflammatory syndromes

Chronic spontaneous urticaria (CSU) requires at least 6 weeks of symptoms for diagnosis 1.

Treatment Algorithm

First-line Treatment

• Second-generation H1 antihistamines (cetirizine, loratadine, fexofenadine) at standard doses 1
  • Preferred for minimal sedation and longer duration of action
  • Cetirizine is preferred in young children

Second-line Treatment (if inadequate response)

• Increase dose of second-generation H1 antihistamines up to 4 times the standard dose 1
  • Example: Cetirizine 10 mg QID or fexofenadine 180 mg QID

Third-line Treatment (if antihistamines fail)

• Omalizumab 300 mg every 4 weeks 1, 2
  • Particularly effective for patients with autoimmune conditions or significant quality of life impairment
  • Allow up to 6 months to assess full response

Acute Severe Flares

• Short-course corticosteroids: Prednisone 0.5-1 mg/kg/day (30-60 mg daily) for 3-7 days until symptoms improve 1
  • Avoid long-term use due to side effects

For Anaphylaxis or Severe Angioedema

• Epinephrine is first-line therapy for respiratory/cardiovascular involvement 1

Special Considerations

Trigger Management

• Identify and avoid triggers, especially for cholinergic urticaria 1:
  • Overheating
  • Strenuous activity
  • Emotional stress
  • Hot baths/showers

Medication Considerations

• Discontinue ACE inhibitors if suspected to cause angioedema 1
• Avoid sedating antihistamines in elderly patients due to fall risk and cognitive impairment 1
• Use corticosteroids cautiously in patients with diabetes, hypertension, osteoporosis, or psychiatric conditions 1

Multimodal Approach for Itch Control

• Second-generation antihistamines
• Emollient cream
• Low-potency topical steroid 1

Common Pitfalls to Avoid

• Excessive laboratory testing in chronic urticaria unless history/exam suggests specific underlying conditions 1
• Long-term corticosteroid use should be restricted to short courses 1
• Overlooking autoimmune causes of chronic urticaria (approximately 30% of cases) 1
• Inadequate antihistamine dosing - many patients require higher than standard doses 1
• Failure to identify physical triggers in inducible urticarias 1
• Using sedating antihistamines in elderly patients 1

Prognosis

• More than 50% of patients with chronic urticaria will have resolution or improvement within one year 1
• Patients with both weals and angioedema tend to have poorer prognosis, with over 50% still having active disease after 5 years 1

Omalizumab Safety Profile

• Generally favorable safety profile with similar adverse event rates to placebo 1, 2
• Most common side effects: headache and upper respiratory tract infection 2
• Warning for anaphylaxis risk requiring initial administration in healthcare setting 1