Treatment of Hives (Urticaria)
Second-generation H1-antihistamines are the first-line treatment for hives (urticaria), with doses that can be increased up to 4 times the standard dose for patients with inadequate response. 1
First-Line Treatment
- Start with second-generation (non-sedating) H1-antihistamines:
- Fexofenadine 180mg daily
- Cetirizine 10mg daily
- Loratadine 10mg daily 1
These medications are preferred over first-generation antihistamines due to their favorable safety profile and minimal sedation. All patients should be offered the choice of at least two different non-sedating antihistamines, as individual responses and tolerance vary 2.
Step-Up Approach for Inadequate Response
- Initial treatment: Standard dose of second-generation antihistamine
- If inadequate response: Increase dose up to 4 times the standard dose (e.g., cetirizine 40mg daily) 1
- If still inadequate: Add one of the following:
- Leukotriene receptor antagonist (e.g., montelukast)
- Omalizumab 300mg subcutaneously every 4 weeks (for chronic spontaneous urticaria)
- Cyclosporine (for severe autoimmune urticaria) at 4mg/kg daily for up to 16 weeks 1
General Measures
Avoid known triggers and aggravating factors:
- Overheating
- Stress
- Alcohol
- NSAIDs (especially in aspirin-sensitive patients)
- ACE inhibitors (particularly if angioedema is present) 2
Topical treatments for symptomatic relief:
- Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide soothing relief 2
Special Considerations
Elderly Patients
Avoid sedating antihistamines due to increased fall risk and cognitive impairment 1.
Emergency Management
For severe symptoms or anaphylaxis, epinephrine is the first-line treatment. It acts on both alpha and beta-adrenergic receptors to reduce vascular permeability, alleviate bronchospasm, and relieve urticaria and angioedema 3.
Medication-Induced Urticaria
In rare cases, antihistamines themselves can cause urticaria. If urticarial lesions worsen after antihistamine treatment, consider antihistamine hypersensitivity and try an antihistamine from a different chemical class 4.
Monitoring and Follow-up
- Regularly assess treatment response using validated tools like UAS7 (Urticaria Activity Score over 7 days)
- Reassess within 1-2 weeks of initiating or changing therapy
- Consider step-down protocols in patients with complete disease control to assess for spontaneous remission 1
Treatment Efficacy
Studies have shown that increasing antihistamine doses improves quality of life without increasing somnolence. Approximately 75% of patients with difficult-to-treat chronic urticaria respond to higher than conventional antihistamine doses 5.
Remember that the prognosis for eventual recovery from ordinary, physical, and vasculitic urticarias is excellent, although some physical urticarias may be especially persistent 2.