What is the treatment for urticaria?

Treatment for Urticaria

Second-generation H1-antihistamines are the first-line treatment for urticaria, with doses that can be increased up to four times the standard dose for refractory cases. 1

Initial Management

First-Line Treatment

• Start with a second-generation H1-antihistamine at standard dosing:
  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily 1

Step-Up Approach

If inadequate response after 1-2 weeks:

1. Step 1: Standard dose second-generation H1-antihistamine
2. Step 2: Increase dose up to 4× standard dose if inadequate response
3. Step 3: Add leukotriene receptor antagonist (e.g., montelukast) or consider advanced therapies 1

Treatment Based on Urticaria Type

Chronic Spontaneous Urticaria

• For patients ≥12 years with chronic spontaneous urticaria who remain symptomatic despite H1 antihistamine treatment, omalizumab is FDA-approved 2
• Dosing of omalizumab for CSU is not dependent on serum IgE levels or body weight 2
• Validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) should be used to monitor disease control 1

Acute Urticaria

• Most cases are self-limited and resolve within days to weeks with appropriate treatment 1
• Limited evidence suggests that adding systemic corticosteroids to antihistamines does not significantly improve symptoms 3

Physical Urticarias

• For symptomatic dermographism, combination therapy with H1 antihistamines and H2 antagonists (e.g., cimetidine, ranitidine) has shown better efficacy than H1 antihistamines alone 1, 4

Advanced Treatment Options for Refractory Cases

Third-Line Options

For patients with inadequate response to high-dose antihistamines:

• Omalizumab: Particularly effective for chronic spontaneous urticaria 1, 2
• Cyclosporine: For resistant cases 1
• Other alternatives: Tacrolimus, mycophenolate mofetil, dapsone, sulfasalazine, and tranexamic acid 1

Topical Treatments

• Topical doxepin may provide relief but should be limited to 8 days and 10% of body surface area (maximum 12g daily) due to risk of allergic contact dermatitis 1

Special Considerations

Anaphylaxis Management

• If urticaria is accompanied by signs of anaphylaxis (respiratory distress, vomiting, lethargy):
  • Administer epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment
  • Follow with combined H1+H2 blockade (diphenhydramine 1-2 mg/kg or 25-50 mg IV plus ranitidine 50 mg IV)
  • Seek immediate emergency medical attention 1

First-Generation Antihistamines

• Use cautiously due to sedative effects
• May be useful for nighttime symptoms when pruritus interferes with sleep 1
• Examples include diphenhydramine and hydroxyzine

Monitoring and Follow-Up

• Reassess within 1-2 weeks of initiating or changing therapy 1
• Follow the principle of "as much as needed and as little as possible" for medication use 1
• Extensive laboratory workup is unnecessary for most cases of urticaria unless specific underlying conditions are suspected 1

Common Pitfalls to Avoid

1. Inadequate dosing: Many patients require higher than standard antihistamine doses. Studies show approximately 75% of patients with difficult-to-treat chronic urticaria respond to higher than conventional antihistamine doses 5

2. Premature discontinuation: More than half of patients with chronic urticaria will have resolution or improvement of symptoms within a year, so continued treatment may be necessary 6

3. Missing anaphylaxis: Failure to identify anaphylaxis can be critical. Always assess for systemic symptoms 1

4. Overuse of corticosteroids: Limited evidence supports their routine use in acute urticaria 3