What is the first line treatment for urticaria?

First-Line Treatment for Urticaria

Second-generation H1-antihistamines are the first-line treatment for urticaria. 1 These medications should be used at standard doses initially and can be increased up to four times the standard dose if the initial response is inadequate.

Treatment Algorithm for Urticaria

Step 1: First-Line Treatment

• Second-generation H1-antihistamines (non-sedating)
  • Examples: fexofenadine 180mg, cetirizine 10mg, loratadine 10mg
  • Should be used regularly, not just when hives occur 2
  • Standard dosing provides remission in approximately 43.1% of patients 3

Step 2: If Inadequate Response to Standard Dose

• Increase dose of second-generation H1-antihistamines up to 4× standard dose 1
• This approach provides remission in about 38.3% of patients who failed standard dosing 3
• Alternatively, consider:
  • Switching to a different second-generation antihistamine (14.8% benefit from switching) 3
  • Combining two different second-generation antihistamines (35.8% remission rate) 3

Step 3: Additional Options for Refractory Cases

• Add H2-antagonists (e.g., cimetidine, ranitidine) to H1-antihistamines
  • Combination therapy shows better efficacy than H1-antihistamines alone 1, 4
• Add leukotriene receptor antagonists (e.g., montelukast)
  • 25% remission rate when added to antihistamines 3
• Short-course systemic corticosteroids for severe flares
  • Reserved for severe, refractory cases that have failed maximal antihistamine therapy 1
  • Use lowest effective dose for shortest duration to minimize adverse effects 1

Step 4: Referral to Specialist for Refractory Chronic Urticaria

• Omalizumab (anti-IgE antibody) - second-line treatment for antihistamine-refractory chronic urticaria 5
• Cyclosporine - third-line treatment, effective in 54-73% of patients 5
• Other options: tacrolimus, mycophenolate mofetil, dapsone, sulfasalazine, tranexamic acid 1

Special Considerations

Acute vs. Chronic Urticaria

• Acute urticaria (< 6 weeks): Focus on symptom control with antihistamines 6
• Chronic urticaria (≥ 6 weeks): Follows stepwise approach above; 80-90% of cases are idiopathic 6
• More than half of patients with chronic urticaria will have resolution or improvement within a year 6

Risk Factors for Antihistamine Refractoriness

• Baseline Urticaria Control Test (UCT) score ≤ 4
• Emergency referral history
• Family history of chronic spontaneous urticaria 3

Monitoring Treatment Response

• Use validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7)
• Reassess within 1-2 weeks of initiating or changing therapy 1
• Follow principle of "as much as needed and as little as possible" for medication use 1

Cautions and Pitfalls

• Avoid routine use of first-generation antihistamines (e.g., diphenhydramine) due to sedative effects; reserve for nighttime symptoms if needed 1
• Limit corticosteroid use to short courses due to adverse effects (15% increase in adverse events, NNH of 9) 1
• Rule out anaphylaxis in acute presentations with urticaria plus systemic symptoms
  • If anaphylaxis is suspected, epinephrine (0.3mg IM in mid-anterolateral thigh) is first-line treatment 1
• Extensive laboratory workup is unnecessary for most cases unless specific underlying conditions are suspected 1