What is the treatment for hives?

Treatment for Hives (Urticaria)

Second-generation H1 antihistamines are the first-line treatment for hives (urticaria), with doses that can be increased up to four times the standard dose for refractory cases. 1

Acute vs. Chronic Urticaria Management

Acute Urticaria Treatment

1. First-line therapy:

   • Second-generation (non-sedating) H1 antihistamines:

     • Fexofenadine 180mg daily
     • Cetirizine 10mg daily
     • Loratadine 10mg daily 1

   • These are preferred due to minimal sedation and favorable safety profile

2. For severe or uncontrolled symptoms:

   • Increase dose of second-generation antihistamines up to 4× standard dose 1
   • For rapid relief in acute settings, diphenhydramine 25-50mg can be used 1, 2

3. For refractory cases:

   • Consider adding H2 antihistamine (e.g., ranitidine 150mg oral) for combined H1+H2 blockade 1
   • Short course of oral corticosteroids (e.g., prednisone) may be used briefly for severe acute episodes 3, 4

Chronic Urticaria Treatment (symptoms >6 weeks)

1. Step 1: Second-generation H1 antihistamines at standard dose 1, 5
2. Step 2: Increase dose up to 4× standard dose if inadequate response 1, 5
3. Step 3: Add leukotriene receptor antagonists or consider referral for advanced therapies:
   • Omalizumab (anti-IgE antibody) - second-line for antihistamine-refractory cases 5
   • Cyclosporine - third-line option, especially effective for autoimmune urticaria 5

Important Clinical Considerations

Medication Selection Tips

• Avoid first-generation antihistamines in elderly patients due to increased fall risk and cognitive impairment 1
• Regular dosing is key - antihistamines should be used on a regular basis, not only after hives appear 4
• Corticosteroids should only be used for short periods (typically at doses equivalent to 40mg prednisone daily) with quick tapering to minimize side effects 4

Special Populations

• Children: Prefer second-generation antihistamines; avoid long-term oral corticosteroids 1
• Elderly: Avoid sedating antihistamines; use second-generation options 1
• Patients with diabetes/hypertension: Use corticosteroids with caution 1

When to Consider Anaphylaxis

If hives present with any of these symptoms, treat as anaphylaxis:

• Respiratory symptoms (shortness of breath, wheezing)
• Obstructive swelling of tongue/lips
• Circulatory symptoms (hypotension)

For anaphylaxis, immediate epinephrine administration is required, followed by H1+H2 antihistamine combination 1, 6

Monitoring and Follow-up

• Reassess within 1-2 weeks of initiating or changing therapy 1
• For chronic urticaria, periodically reassess the need for continued therapy 1
• Most patients with chronic urticaria will have resolution or improvement within a year 7

Common Pitfalls to Avoid

• Don't undertreat: Many patients require higher than standard antihistamine doses
• Don't rely on sedating antihistamines as first-line therapy due to side effects
• Don't use long-term corticosteroids for chronic urticaria management
• Don't forget to assess for underlying causes in chronic urticaria, though 80-90% are idiopathic 7

Remember that urticaria significantly impacts quality of life, with approximately 40% of chronic urticaria patients reporting a very large negative effect on quality of life 5. Prompt and effective treatment is essential for symptom control and improving patient wellbeing.