What is the treatment for hives resulting from prednisone (corticosteroid) withdrawal?

Treatment for Hives from Prednisone Withdrawal

For hives resulting from prednisone withdrawal, the most effective treatment is to immediately reintroduce prednisone at 15 mg daily and follow a more gradual tapering schedule, combined with antihistamines.

Understanding Prednisone Withdrawal Hives

Prednisone withdrawal can trigger an immune-mediated reaction manifesting as hives (urticaria). This occurs due to:

• Sudden decrease in anti-inflammatory effects
• Rebound immune system hyperactivity
• Possible adrenal insufficiency with systemic symptoms

Treatment Algorithm

Step 1: Immediate Management

• Reintroduce prednisone at 15 mg daily for 1 week 1
• Add a non-sedating antihistamine at standard dose (such as levocetirizine 5 mg or desloratadine 5 mg daily) 2

Step 2: Modified Tapering Schedule

Follow this more gradual tapering schedule:

• 15 mg daily for 1 week
• 10 mg daily for 1 week
• 5 mg daily for 1 week
• 2.5 mg daily for 1 week
• Then discontinue 1

Step 3: Antihistamine Management

• Continue antihistamines throughout the tapering period and for 1-2 weeks after prednisone discontinuation
• If standard antihistamine doses are insufficient, consider:
  • Increasing antihistamine dose up to 4 times the standard dose 2
  • Using antihistamines on a regular schedule, not as needed 3

Special Considerations

For Severe Cases

If hives are severe or accompanied by systemic symptoms:

• Consider a higher initial prednisone reintroduction dose (20-25 mg)
• Taper more slowly (decrease by 2.5 mg every 1-2 weeks)
• Add a second antihistamine (H2 blocker) such as famotidine

For Mild Cases

If hives are mild and localized:

• Consider a lower reintroduction dose (10 mg)
• Add topical corticosteroids to affected areas

Monitoring and Follow-up

• Assess response within 24 hours of prednisone reintroduction (improvement should be noticeable quickly) 4
• Monitor for resolution of hives during tapering
• If symptoms worsen during tapering, return to previous effective dose and slow the taper schedule

Important Caveats

• Never abruptly discontinue prednisone again as this increases risk of adrenal insufficiency and withdrawal symptoms 1
• Approximately 47% of patients with antihistamine-resistant urticaria achieve remission with a short course of prednisone 4
• Be aware that in rare cases, patients may have an allergic reaction to prednisone itself, which would present differently from withdrawal symptoms 5
• If symptoms persist despite reintroduction and proper tapering, consider alternative diagnoses or referral to an allergist/immunologist

Prevention of Future Episodes

• Always follow a gradual tapering schedule when discontinuing prednisone
• Educate patients about the risks of self-discontinuation
• Consider prophylactic antihistamines during future prednisone tapers if patient has history of withdrawal hives

This approach prioritizes quickly restoring anti-inflammatory effects while providing symptomatic relief, followed by a controlled withdrawal to minimize recurrence of symptoms.