What is the treatment for urticaria?

Urticaria Treatment

The treatment of urticaria follows a stepwise algorithm, starting with standard-dose second-generation H1-antihistamines, increasing to up to 4 times the standard dose if needed, followed by omalizumab as add-on therapy for refractory cases, and cyclosporine as a third-line option. 1

First-Line Treatment: Second-Generation H1-Antihistamines

• Standard dose options:

  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Desloratadine 5mg daily
  • Levocetirizine 5mg daily
  • Bilastine 20mg daily 1

• Key advantages: Second-generation antihistamines are preferred over first-generation ones (like diphenhydramine) due to:

  • Less sedation and cognitive impairment
  • Fewer anticholinergic effects
  • More convenient dosing schedules (once or twice daily) 1

Step-Up Approach for Inadequate Response

Step 2: Increase Antihistamine Dose

• If inadequate response after 1-2 weeks, increase second-generation antihistamine dose up to 4 times the standard dose 1
• For example:
  • Cetirizine 20-40mg daily
  • Fexofenadine 360-720mg daily
  • Loratadine 20-40mg daily

Step 3: Add-on Therapies for Refractory Cases

• Omalizumab: 300mg subcutaneously every 4 weeks

  • FDA-approved for chronic spontaneous urticaria in adults and adolescents 12 years and older who remain symptomatic despite H1 antihistamine treatment 1, 2
  • In clinical trials, significantly more patients treated with omalizumab 300mg (36%) reported complete resolution of symptoms (no itch, no hives) at Week 12 compared to placebo (9%) 2
  • Safety note: Monitor for anaphylaxis, which can occur with omalizumab administration 1, 2

• Cyclosporine: Up to 5mg/kg body weight

  • Third-line option for refractory cases
  • Requires monitoring of blood pressure and renal function (BUN and creatinine) every 6 weeks
  • Potential risks include hypertension, epilepsy in predisposed individuals, hirsutism, gum hypertrophy, and renal failure 1

Additional Treatment Options

• Leukotriene receptor antagonists (e.g., montelukast) as add-on therapy 1
• H1+H2 combination therapy: Adding H2 antagonists (e.g., ranitidine, cimetidine) may enhance efficacy, particularly for symptomatic dermographism 1
• Other options for resistant cases include tacrolimus, mycophenolate mofetil, dapsone, sulfasalazine, and tranexamic acid 1

Monitoring and Treatment Adjustment

• Use validated tools like the Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control 1
• Reassess treatment response within 1-2 weeks of initiating or changing therapy 1
• Consider step-down only after at least 3 consecutive months of complete control
• Step down gradually by reducing antihistamine dose (not more than 1 tablet per month)
• If control is lost during step-down, return to the last effective dose 1

Special Considerations

Acute Urticaria vs. Chronic Urticaria

• The above treatment approach applies primarily to chronic urticaria (lasting >6 weeks)
• For acute urticaria, second-generation antihistamines remain first-line treatment
• The addition of corticosteroids to antihistamines for acute urticaria has shown inconsistent benefits 3

Anaphylaxis Management

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

Pediatric Patients

• Start with age-appropriate dosing of second-generation H1-antihistamines
• Medication dosing must be weight-based
• Food allergies are a common cause of urticaria in infants and may require evaluation by an allergist 1

Common Pitfalls to Avoid

1. Using first-generation antihistamines as first-line: These cause significant sedation and cognitive impairment
2. Inadequate dosing: Not increasing antihistamine dose before declaring treatment failure
3. Prolonged corticosteroid use: Should be limited to short courses for severe exacerbations
4. Failure to identify anaphylaxis: If urticaria is accompanied by respiratory distress, vomiting, lethargy, or persistent crying, treat as anaphylaxis
5. Not monitoring for medication side effects: Particularly with higher-dose antihistamines, omalizumab, or cyclosporine

Following this stepwise approach will optimize treatment outcomes while minimizing side effects for patients with urticaria.