What is the treatment for urticaria?

Urticaria Treatment

The treatment of urticaria follows a stepwise approach, 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 dosing options:

  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Desloratadine, bilastine, or levocetirizine at standard doses 1

• Key advantages: Second-generation antihistamines have minimal sedative and anticholinergic effects compared to first-generation options 1

• Administration guidance: Antihistamines should be used on a regular basis, not just when hives occur 1

Step-Up Approach for Inadequate Response

Step 1: Dose Escalation

• If standard dose is ineffective, increase second-generation H1-antihistamine dose up to 4× standard dose 1
• Monitor for increased side effects, though second-generation antihistamines remain safer than first-generation options even at higher doses

Step 2: Add-on Therapies

For patients who remain symptomatic despite up-dosed antihistamines:

• Omalizumab (preferred):

  • Dosage: 300mg subcutaneously every 4 weeks
  • FDA-approved for chronic spontaneous urticaria in adults and adolescents 12+ years who remain symptomatic despite H1-antihistamine treatment 1, 2
  • Monitor for potential anaphylaxis after administration 1

• Alternative add-ons:

  • Leukotriene receptor antagonists (e.g., montelukast) 1
  • H2 antagonists (e.g., ranitidine, cimetidine) - particularly effective for symptomatic dermographism when combined with H1 antihistamines 1

Step 3: Refractory Cases

• Cyclosporine:

  • Dosage: Up to 5mg/kg body weight
  • Requires monitoring of blood pressure and renal function (BUN and creatinine) every 6 weeks
  • Potential risks: hypertension, epilepsy in predisposed individuals, hirsutism, gum hypertrophy, and renal failure 1

• Other options for treatment-resistant cases:

  • Tacrolimus, mycophenolate mofetil, dapsone, sulfasalazine, tranexamic acid 1

Special Considerations

Acute Severe Urticaria with Anaphylaxis

If urticaria presents with signs of anaphylaxis:

1. Administer epinephrine 0.3 mg IM in mid-anterolateral thigh (first-line treatment)
2. Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV)
3. Seek immediate emergency medical attention 1

Pediatric Patients

• Start with age-appropriate, weight-based dosing of second-generation H1-antihistamines
• Identify and avoid triggers, particularly food allergies which are common in infants 1

Nighttime Symptoms

• First-generation antihistamines (e.g., diphenhydramine) may be useful specifically for nighttime symptoms due to their sedative effects 1
• Use cautiously due to anticholinergic side effects

Monitoring and Follow-up

• Use validated tools like the Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control
• Consider step-down only after at least 3 consecutive months of complete control
• When reducing medication, decrease antihistamine dose gradually (not more than 1 tablet per month) 1

Treatment Pitfalls to Avoid

1. Overuse of systemic corticosteroids: While sometimes used for short-term control in severe flares, they are not recommended for long-term management due to side effects 1, 3

2. Premature step-down: Maintain effective therapy for at least 3 months of complete control before attempting to reduce medication 1

3. Inadequate dosing: Many patients require higher than standard doses of antihistamines for effective control 1

4. Overlooking anaphylaxis: Always assess for signs of anaphylaxis, which requires immediate epinephrine administration 1

5. Neglecting to identify triggers: Identifying and avoiding triggers is crucial, particularly in cases like Alpha-Gal syndrome where avoiding mammalian meat products is essential 1