What is the treatment for urticaria?

Treatment of Urticaria

Second-generation H1 antihistamines are the first-line treatment for urticaria, with dose escalation up to four times the standard dose for inadequate response. 1, 2

Classification and Diagnosis

Urticaria is characterized by pruritic wheals (hives) that typically last less than 24 hours, sometimes accompanied by angioedema. It is classified based on duration:

• Acute urticaria: Lasts less than 6 weeks
• Chronic urticaria: Lasts more than 6 weeks
  • Chronic spontaneous urticaria (CSU): No specific external trigger
  • Chronic inducible urticaria (CIndU): Specific triggers identified

The diagnosis is primarily clinical, with investigations guided by history and physical examination.

Treatment Algorithm

Step 1: First-line Treatment

• Second-generation H1 antihistamines (non-sedating) at standard doses 1, 2
  • Examples: Cetirizine 10mg, Loratadine 10mg, Fexofenadine 180mg daily
  • Preferred over first-generation antihistamines due to fewer sedative and anticholinergic effects

Step 2: Dose Escalation

• If inadequate response after 2-4 weeks, increase dose up to 4 times the standard dose 2
  • Example: Cetirizine up to 40mg daily

Step 3: Add-on Therapies

For refractory cases, consider:

• Leukotriene receptor antagonists (e.g., Montelukast) 2
• H2 antihistamines as adjunctive therapy 1, 3
• Brief corticosteroid bursts (short-term use only, 3-7 days) 4

Step 4: Specialist Referral and Advanced Therapies

For severe, refractory chronic urticaria:

• Omalizumab (anti-IgE monoclonal antibody) 2, 5
• Cyclosporine for autoimmune urticaria 3, 5

Special Considerations

Acute Management of Anaphylaxis

If urticaria is accompanied by signs of anaphylaxis:

• Epinephrine is the first-line treatment (intramuscular) 2
• Follow with combined H1+H2 blockade 2
• Seek emergency care immediately

Trigger Avoidance

• Identify and avoid specific triggers when possible 4, 6
• Common triggers include:
  • Foods and food additives
  • Medications (especially NSAIDs, aspirin)
  • Physical stimuli (pressure, cold, heat)
  • Infections

Monitoring and Follow-up

• Regular assessment of treatment response using validated tools like the Urticaria Activity Score (UAS7) 1, 2
• Reassess within 1-2 weeks of initiating or changing therapy 2
• Consider step-down protocols in patients with complete disease control 2

Prognosis

More than half of patients with chronic urticaria will experience resolution or improvement of symptoms within one year 4, 7. However, some cases may persist for several years, requiring ongoing management.

Pitfalls to Avoid

• Don't overinvestigate: Extensive laboratory workup is unnecessary for most cases of urticaria unless specific underlying conditions are suspected 1, 4
• Don't rely on first-generation antihistamines as first-line due to sedation and anticholinergic effects 2
• Don't use long-term systemic corticosteroids due to adverse effects 4
• Don't overlook autoimmune urticaria: About one-third of children with chronic urticaria have autoantibodies against IgE receptors 3