What is the treatment for recurrent urticaria?

Treatment for Recurrent Urticaria

Second-generation H1-antihistamines (e.g., fexofenadine 180mg, cetirizine 10mg, loratadine 10mg) are the first-line treatment for recurrent urticaria, with doses that can be increased up to four times the standard dose if needed for symptom control. 1

First-Line Treatment

• Start with standard doses of non-sedating second-generation antihistamines:
  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily

These medications have a favorable safety profile with minimal sedation compared to first-generation antihistamines 1, 2.

Step-Up Approach

If inadequate response to standard doses:

1. Increase antihistamine dose: Titrate up to 4× standard dose (e.g., cetirizine 40mg daily) 1, 3

   • This approach is effective in approximately 23% of patients who fail standard dosing 3
   • Higher than 4× dosing may be considered in refractory cases, with reported effectiveness in 49% of patients and minimal increase in side effects 3

2. Add-on therapy (if increased antihistamine dosing is insufficient):

   • Leukotriene receptor antagonists (e.g., montelukast) 1, 4
   • Omalizumab 300mg subcutaneously every 4 weeks 1
     • Significantly reduces itch severity, hive number/size, and improves quality of life
     • Observe patients for 30 minutes after injection (2 hours for first three injections)
   • Cyclosporine (4mg/kg daily for approximately 16 weeks) 1
     • Effective in about two-thirds of patients with severe antihistamine-resistant urticaria

Symptomatic Relief

• Topical treatments for symptom relief:
  • Cooling antipruritic lotions (calamine, 1% menthol in aqueous cream) 1
  • Topical calcineurin inhibitors for genital urticaria (tacrolimus 0.03-0.1%, pimecrolimus 1%) 1

Important Considerations

Avoid Triggers

• Identify and avoid known triggers:
  • Overheating
  • Stress
  • Alcohol
  • NSAIDs (especially in aspirin-sensitive patients)
  • ACE inhibitors (particularly if angioedema is present) 1

Special Populations

• Elderly: Avoid sedating antihistamines due to increased fall risk and cognitive impairment 1
• Children: Avoid long-term oral corticosteroids 1
• Patients with comorbidities: Use corticosteroids with caution in patients with diabetes, hypertension, osteoporosis, or psychiatric conditions 1

Monitoring

• Reassess treatment response within 1-2 weeks of initiating or changing therapy
• Use validated tools like UAS7 (Urticaria Activity Score over 7 days) 1
• Periodically reassess need for continued therapy using an "as much as needed and as little as possible" approach 1

Emergency Management

• For severe symptoms or anaphylaxis:
  • Administer epinephrine immediately
  • Seek emergency medical attention 1

Common Pitfalls to Avoid

1. Using sedating antihistamines: First-generation antihistamines alter REM sleep patterns and learning curves without superior efficacy 4
2. Inadequate dose escalation: Many patients require higher than standard doses for symptom control 1, 3
3. Extensive laboratory workup: Only limited non-specific testing should be considered unless history or examination suggests specific underlying conditions 2
4. Prolonged corticosteroid use: Should be limited to brief bursts as adjunctive therapy 2
5. Premature referral to specialists: Consider higher antihistamine doses before moving to third-line treatments 1, 3

The prognosis for chronic urticaria is generally favorable, with more than half of patients experiencing resolution or improvement of symptoms within a year 2.