What is the treatment for urticaria (hives) without pruritus (itching)?

Treatment for Hives Without Itching

The first-line treatment for urticaria (hives) without pruritus (itching) is non-sedating H1-antihistamines such as cetirizine 10 mg, fexofenadine 180 mg, or loratadine 10 mg daily. 1, 2

First-Line Treatments

Non-sedating Antihistamines

• First choice: Non-sedating H1-antihistamines at standard doses:
  • Cetirizine 10 mg daily
  • Fexofenadine 180 mg daily
  • Loratadine 10 mg daily
  • Desloratadine 5 mg daily

Even without itching, these medications help reduce the inflammatory response causing the hives by blocking histamine receptors 1, 2.

Topical Treatments

• Moderate to high-potency topical corticosteroids (e.g., mometasone furoate 0.1% or betamethasone valerate 0.1%)
• Menthol 0.5% preparations for cooling effect
• Emollients to maintain skin hydration 2

Second-Line Treatments

Dose Escalation

If standard doses are ineffective, guidelines support increasing the dose of second-generation H1-antihistamines up to 4 times the standard dose when benefits outweigh risks 1.

Combination Therapy

• H1 + H2 antagonist combinations (e.g., fexofenadine with cimetidine) may be more effective than H1 antagonists alone 3
• Evidence shows that ranitidine combined with diphenhydramine is more effective than diphenhydramine alone (RR 1.59,95% CI 1.07 to 2.36) 3

Third-Line Treatments

Immunomodulatory Agents

For severe or refractory cases:

• Montelukast (antileukotriene) - may benefit aspirin-sensitive urticaria 1
• Short courses of oral corticosteroids (e.g., prednisolone 50 mg daily for 3 days) for acute severe episodes 1

Other Systemic Options

• Doxepin - acts as a potent histamine antagonist in both topical and oral forms 2
• Mirtazapine - may be helpful for various types of urticaria 2

Special Considerations

Physical Urticaria

• Physical urticarias (triggered by pressure, cold, heat, etc.) typically have weals lasting less than 1 hour (except delayed pressure urticaria) 1
• Identify and avoid physical triggers when possible
• For symptomatic dermatographism, a combination of an antihistamine and an H2 antagonist (e.g., chlorphenamine and cimetidine) appears effective 4

Duration of Treatment

• For acute urticaria: Short-term treatment (up to 2 weeks) is usually sufficient
• For chronic urticaria: Intermediate-term treatment (2 weeks to 3 months) may be necessary 5

Monitoring and Follow-up

• Assess response to treatment after 2-4 weeks
• If no improvement, consider:
  1. Increasing antihistamine dose
  2. Adding H2 antagonist
  3. Switching to a different antihistamine
  4. Referral to dermatology for consideration of immunomodulatory therapy

Treatment Algorithm

1. Start with standard dose non-sedating H1-antihistamine
2. If inadequate response after 2 weeks, increase dose up to 4x standard
3. If still inadequate, add H2 antagonist or switch antihistamine class
4. For severe or refractory cases, consider short course of oral corticosteroids
5. For chronic cases not responding to above measures, consider referral for immunomodulatory therapy

Cautions

• Sedating antihistamines (hydroxyzine, chlorphenamine) should be avoided in the elderly and those with liver disease due to increased risk of sedation 1
• Long-term use of sedative antihistamines may predispose patients to dementia 2
• Antihistamines should be used with caution during pregnancy, especially in the first trimester 1

The evidence suggests that while antihistamines are the mainstay of treatment for urticaria, their effectiveness may vary between individuals, and combination therapy may be necessary for optimal management 5, 4.