What is the recommended treatment for urticaria?

Treatment for Urticaria

The recommended first-line treatment for urticaria is second-generation H1-antihistamines at standard doses, with a stepwise approach of increasing to up to 4 times the standard dose for inadequate response, followed by omalizumab as second-line therapy and cyclosporine as third-line therapy for refractory cases. 1

First-Line Treatment: Second-Generation H1-Antihistamines

• Start with standard-dose second-generation H1-antihistamines:
  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Desloratadine 5mg daily
  • Bilastine 20mg daily
  • Levocetirizine 5mg daily 1

These newer antihistamines are preferred over first-generation options (like diphenhydramine) because they cause significantly less sedation and psychomotor impairment while maintaining efficacy 2, 3.

Stepwise Treatment Algorithm

Step 1: Standard-dose second-generation H1-antihistamines

• Assess response after 2-4 weeks

Step 2: If inadequate control, increase dose up to 4 times the standard dose

• Bilastine and levocetirizine have been safely up-dosed to four times the standard dose 1, 4
• Fexofenadine has been studied at three times the conventional dose 4
• Note: Cetirizine up-dosing may increase risk of sedation 4

Step 3: For refractory cases, add omalizumab

• 300mg every 4 weeks or 600mg every 2 weeks 1

Step 4: If inadequate control within 6 months, add cyclosporine

• Up to 5mg/kg body weight
• Monitor blood urea nitrogen and creatinine levels every 6 weeks 1

Additional Treatment Options

• H1+H2 Combination Therapy: Adding H2 antagonists (cimetidine, ranitidine) to H1 antihistamines shows better efficacy than H1 antihistamines alone, particularly for symptomatic dermographism 1, 2, 5

• Leukotriene Receptor Antagonists: Montelukast can be used as add-on therapy for antihistamine-resistant urticaria 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

Acute Urticaria vs. Chronic Urticaria

• The evidence for corticosteroid use in acute urticaria is mixed. Two out of three RCTs showed no improvement when adding prednisone to antihistamines 5
• For chronic urticaria, follow the stepwise approach outlined above 1

Anaphylaxis Management

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

Treatment Monitoring and Adjustment

• Follow the principle of "as much as needed and as little as possible" 1
• Consider step-down only after at least 3 consecutive months of complete control
• Reduce antihistamine dose gradually (not more than 1 tablet per month)
• If control is lost during step-down, return to the last effective dose 1
• Use validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control 1

Common Pitfalls to Avoid

1. Using first-generation antihistamines as first-line therapy: These cause significant sedation and anticholinergic effects. Reserve them for nighttime symptoms only 1, 3

2. Inadequate dose escalation: Many physicians hesitate to up-dose antihistamines despite guidelines recommending this approach 4

3. Premature addition of immunomodulators: Follow the stepwise approach before moving to more aggressive therapies 1

4. Missing anaphylaxis: Failure to identify anaphylaxis can be critical. Be vigilant for signs beyond simple urticaria 1

5. Excessive laboratory workup: Extensive laboratory testing is unnecessary for most patients with chronic urticaria 1