What is the best treatment for premenstrual cycle (premenstrual syndrome, PMS) hives?

Treatment of Premenstrual Cycle Hives

Second-generation H1 antihistamines are the first-line treatment for premenstrual cycle hives, with dose escalation up to four times the standard dose if needed for symptom control. These medications provide effective relief with minimal sedation and fewer anticholinergic effects compared to first-generation alternatives 1.

Understanding Premenstrual Hives

Premenstrual hives occur in approximately half of women with underlying skin conditions, typically appearing during the premenstrual week 2. This phenomenon is associated with hormonal fluctuations and is often related to premenstrual syndrome (PMS) symptoms 3.

Treatment Algorithm

First-Line Therapy:

• Second-generation H1 antihistamines:
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Fexofenadine 180mg daily

If Inadequate Response:

• Increase antihistamine dose up to 4 times the standard dose 1
• For example: Cetirizine 20mg twice daily

For Persistent or Severe Cases:

1. Consider adding H2 antihistamines (such as ranitidine)
2. For cases with significant PMS symptoms, calcium supplementation may help reduce both emotional and physical symptoms, including hives 4
3. For severe, refractory cases, consult with an allergist/immunologist for consideration of:
   • Leukotriene receptor antagonists
   • Oral corticosteroids (short course during premenstrual phase only)

Special Considerations

Hormonal Management

For women with severe, recurrent premenstrual hives that don't respond to antihistamines:

• Consider hormonal interventions such as low-dose combined hormonal contraceptives 5
• GnRH analogues may be considered for short-term use (up to 6 months) in severe cases 5
• Note: Avoid combined hormonal contraceptives in women with migraine with aura due to increased stroke risk 5

Monitoring and Follow-up

• Track hive patterns in relation to menstrual cycle using a symptom calendar
• Reassess treatment effectiveness after 2-3 months
• Consider reducing medication during non-premenstrual phases if symptoms are cyclical

Important Cautions

• First-generation antihistamines (like diphenhydramine) should be avoided as primary treatment due to sedation and anticholinergic effects 1
• Long-term corticosteroid use should be avoided due to potential adverse effects 1
• If hives are accompanied by symptoms of anaphylaxis (difficulty breathing, severe swelling, hypotension), epinephrine is the first-line treatment, and emergency care should be sought immediately 5

Additional Supportive Measures

• Avoid known triggers during the premenstrual period
• Wear loose, non-irritating clothing
• Use mild, fragrance-free soaps and moisturizers
• Consider stress reduction techniques, as stress can exacerbate hives
• Some evidence suggests calcium supplementation (1000mg daily) may help reduce PMS symptoms, including skin manifestations 4

For patients with severe, treatment-resistant premenstrual hives, specialized evaluation for progesterone sensitivity may be warranted, as some cases have shown response to progesterone therapy 6.