What is the treatment for urticaria?

Treatment of Urticaria

Second-generation H1-antihistamines are the first-line treatment for urticaria, with dose escalation up to 4 times the standard dose for inadequate response, followed by omalizumab or cyclosporine as add-on therapy for refractory cases. 1

Stepwise Treatment Algorithm

Step 1: First-Line Treatment

• Start with standard-dose second-generation (non-sedating) H1-antihistamines:
  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Desloratadine, bilastine, or levocetirizine at standard doses 1

Step 2: Dose Escalation

• If inadequate response after 2-4 weeks, increase dose up to 4 times the standard dose
• For example:
  • Fexofenadine 180mg four times daily
  • Cetirizine 10mg four times daily 1

Step 3: Add-on Therapies for Refractory Cases

• For patients who remain symptomatic despite up-dosed antihistamines (UCT score ≤11):
  • Omalizumab: 300mg subcutaneously every 4 weeks (FDA-approved for chronic spontaneous urticaria in adults and adolescents ≥12 years) 1
  • Cyclosporine: Up to 5mg/kg body weight (requires monitoring of blood pressure and renal function every 6 weeks) 1
  • Leukotriene receptor antagonists (e.g., montelukast) as adjunctive therapy 1, 2

Special Considerations

Acute Urticaria with Anaphylaxis

• If urticaria is accompanied by signs of anaphylaxis (hypotension, respiratory distress, etc.):
  1. Epinephrine 0.3mg IM in mid-anterolateral thigh as first-line treatment 1, 3
  2. Combined H1+H2 blockade (diphenhydramine 25-50mg IV plus ranitidine 50mg IV) 1
  3. Seek immediate emergency medical attention 1

Combination Therapy Options

• H1 + H2 antagonist combination (e.g., cetirizine + ranitidine) may be more effective than H1 antihistamines alone, particularly for symptomatic dermographism 1, 4, 5
• Recent evidence shows that adding corticosteroids to antihistamines for acute urticaria may not provide additional benefit 6

Alternative Therapies for Resistant Cases

• Dapsone
• Sulfasalazine
• Tranexamic acid
• Tacrolimus
• Mycophenolate mofetil 1

Monitoring and Follow-up

• Use validated tools to assess disease control:
  • Urticaria Control Test (UCT): Score ≥12 indicates well-controlled disease
  • Urticaria Activity Score (UAS7) 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) 1

Special Populations

• Pediatric patients: Use age-appropriate, weight-based dosing of second-generation H1-antihistamines 1
• Pregnant women: Second-generation antihistamines (particularly loratadine and cetirizine) are preferred due to established safety profiles
• Elderly: Use caution with first-generation antihistamines due to anticholinergic effects and sedation 2

Important Cautions

• First-generation antihistamines (e.g., diphenhydramine) should be used cautiously due to sedative effects, though they may be useful for nighttime symptoms 1, 2
• Avoid sedating antihistamines when possible as they affect REM sleep patterns and learning curves without superior efficacy 2
• Monitor for anaphylaxis with omalizumab administration 1
• When using cyclosporine, monitor for hypertension, renal dysfunction, hirsutism, and gum hypertrophy 1

The evidence strongly supports a stepwise approach to urticaria management, focusing on symptom control while minimizing side effects. Second-generation antihistamines remain the cornerstone of therapy, with dose escalation and add-on therapies reserved for refractory cases.