Can dexamethasone be used to treat hives?

Dexamethasone for Hives Treatment

Dexamethasone can be used to treat hives (urticaria), but it should not be considered first-line therapy due to limited evidence of benefit and potential for adverse effects. 1, 2

Treatment Algorithm for Hives

First-line Treatment

• Second-generation H1 antihistamines (e.g., cetirizine, fexofenadine, loratadine) at standard doses 3
• If inadequate response, increase dose up to 4 times the standard dose 3

Second-line Treatment (for severe or refractory cases)

• Add leukotriene receptor antagonists (e.g., montelukast) 3
• Consider H2 antagonists in combination with H1 antihistamines 3

Third-line Treatment (for severe, refractory cases only)

• Consider short-course systemic corticosteroids like dexamethasone when:
  • Severe symptoms persist despite maximal antihistamine therapy
  • Rapid relief is needed for significant discomfort or functional impairment
  • Dosing: Individualized based on severity (typically 0.5-9 mg/day) 4

Evidence Analysis

Corticosteroid Efficacy

Recent high-quality evidence shows limited benefit of adding corticosteroids to antihistamines for acute urticaria. A 2021 randomized controlled trial found no significant difference in pruritus scores at 60 minutes when comparing IV chlorpheniramine alone versus IV chlorpheniramine plus IV dexamethasone 1. Furthermore, patients receiving oral prednisolone for 5 days after IV dexamethasone showed higher urticaria activity at 1-week and 1-month follow-ups 1.

However, a 2024 meta-analysis found that for patients with low to moderate probability of improvement with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by 14-15% (NNT=7). For patients highly responsive to antihistamines, the benefit was minimal (2.2% improvement, NNT=45) 2.

Safety Considerations

Corticosteroids increase adverse events by approximately 15% (number needed to harm = 9) 2. Potential adverse effects include:

• Persistent hiccups 5
• Perineal burning sensation (particularly in female patients) 6
• Rare but serious hypersensitivity reactions 7

Special Situations

Allergic Reactions to Chemotherapy

For urticaria related to chemotherapy infusion reactions, dexamethasone is specifically recommended as part of management protocols:

• For grade 1/2 reactions: Stop or slow infusion rate and provide symptomatic treatment including dexamethasone 8
• For grade 3/4 reactions: Stop treatment and provide aggressive symptomatic therapy including corticosteroids 8

Premedication for High-Risk Patients

Dexamethasone is recommended as premedication for patients receiving certain chemotherapy agents with high risk of infusion reactions:

• For docetaxel: Oral dexamethasone 8 mg twice daily for 3 days (starting 1 day before administration) 8
• For paclitaxel: IV dexamethasone plus diphenhydramine and H2 receptor antagonist 30 minutes before infusion 8

Perioperative Antiemetic Use

Dexamethasone (4-5 mg) is effective for PONV prevention with similar efficacy to higher doses (8-10 mg) 8. This may indirectly help manage urticaria symptoms in the perioperative setting.

Key Recommendations for Clinical Practice

1. Reserve dexamethasone for severe, refractory urticaria cases that have failed maximal antihistamine therapy
2. Use the lowest effective dose for the shortest duration to minimize adverse effects
3. Monitor for adverse reactions including hiccups, perineal burning, and rare hypersensitivity reactions
4. Consider dexamethasone as part of management protocols for chemotherapy-related urticaria/infusion reactions
5. Avoid prolonged corticosteroid therapy as it may be associated with persistent urticaria activity

In conclusion, while dexamethasone can be used for hives treatment, its use should be limited to specific situations where the benefits outweigh the risks, and it should not replace standard first-line therapy with antihistamines.