What is the first line treatment for patients presenting with hives (urticaria)?

First-Line Treatment for Urticaria (Hives)

Second-generation H1 antihistamines are the first-line treatment for patients presenting with hives (urticaria). 1

Treatment Algorithm for Urticaria

First-Line Therapy

• Start with a second-generation (non-sedating) H1 antihistamine such as:
  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily 1

These medications should be used regularly, not just when hives appear, to maintain consistent symptom control 2.

If Inadequate Response

1. Increase the dose of the second-generation antihistamine up to 4 times the standard dose 1, 3

   • Research shows that increasing antihistamine doses improves quality of life without significantly increasing somnolence 3
   • Approximately 75% of patients with difficult-to-treat urticaria respond to higher than conventional antihistamine doses 3

2. Consider adding adjunctive therapy if symptoms persist:

   • H2 antihistamines can be used as additional therapy 1
   • Leukotriene receptor antagonists may be beneficial 1

Special Considerations

Acute vs. Chronic Urticaria

• Acute urticaria: Lasts less than 6 weeks
• Chronic urticaria: Lasts more than 6 weeks 1, 4

Both types respond to second-generation antihistamines as first-line therapy, though chronic cases may require higher doses or additional treatments 4.

For Severe or Refractory Cases

• Short courses of oral corticosteroids (e.g., prednisone 40mg daily) may be used briefly for severe flares 2
• The goal should be to quickly reach an effective low dose followed by discontinuation 2
• For chronic urticaria unresponsive to antihistamines, omalizumab (anti-IgE monoclonal antibody) is an effective second-line treatment 4

If Urticaria is Accompanied by Anaphylaxis

• Epinephrine is the first-line treatment
• Combined H1+H2 blockade should follow
• Emergency care should be sought immediately 1

Monitoring and Follow-up

• Reassess treatment response within 1-2 weeks of initiating or changing therapy 1
• Use validated tools like the Urticaria Activity Score (UAS7) to monitor progress 1
• Follow the principle of "as much as needed and as little as possible" for medication dosing 1

Common Pitfalls to Avoid

1. Using sedating first-generation antihistamines as first-line therapy - second-generation agents are preferred due to better side effect profiles
2. Inadequate dosing - many patients require higher than standard doses for symptom control
3. Long-term corticosteroid use - should be limited to short courses for severe flares
4. Unnecessary laboratory workup - extensive testing is not needed for most cases of urticaria unless specific underlying conditions are suspected 1

Second-generation antihistamines are clearly established as the cornerstone of urticaria management, with dose escalation as the next step before considering additional therapies.