What is the treatment for urticaria?

Treatment of Urticaria

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 are recommended as first-line treatment:
  • Fexofenadine 180mg
  • Cetirizine 10mg
  • Loratadine 10mg
  • Desloratadine
  • Bilastine
  • Levocetirizine 1

These medications are preferred over first-generation antihistamines due to their lower sedative effects. However, first-generation antihistamines may be useful for nighttime symptoms 1.

Stepwise Management Algorithm

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

• Begin with standard dosing of a second-generation antihistamine
• Monitor response using validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) 1

Step 2: Up-dosing of antihistamines

• If inadequate response to standard dose, increase to up to 4 times the standard dose
• Example: Cetirizine 10mg → 40mg daily 1

Step 3: Add-on therapies for resistant cases

• Omalizumab: 300mg every 4 weeks or 600mg every 2 weeks

  • FDA-approved for chronic spontaneous urticaria in adults and adolescents 12 years and older who remain symptomatic despite H1 antihistamine treatment
  • Monitor for anaphylaxis risk 1

• Cyclosporine: Up to 5mg/kg body weight

  • Requires monitoring of blood pressure and renal function every 6 weeks
  • Potential risks: hypertension, epilepsy in predisposed individuals, hirsutism, gum hypertrophy, and renal failure 1

• Additional options:

  • Leukotriene receptor antagonists (e.g., montelukast)
  • H2 antagonists (e.g., ranitidine) in combination with H1 antihistamines
  • Tacrolimus, mycophenolate mofetil, dapsone, sulfasalazine, tranexamic acid 1, 2

Special Considerations

Acute Urticaria with Anaphylaxis

If urticaria is accompanied by signs of anaphylaxis:

1. Epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment 1, 3
2. Combined H1+H2 blockade (typically diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV) 1
3. Seek immediate emergency medical attention 1

Chronic Urticaria Management

• 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
• More than half of patients with chronic urticaria will have resolution or improvement of symptoms within one year 4, 2

Pediatric Patients

• Use 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 and Caveats

1. Trigger identification: Triggers can be identified in only 10-20% of patients with chronic urticaria, so don't delay treatment while searching for triggers 4, 2

2. Overuse of corticosteroids: While brief corticosteroid bursts may be used as adjunctive treatment, long-term use should be avoided due to side effects 1, 2

3. Limited laboratory workup: For chronic urticaria, only a simple laboratory workup is needed unless the history or physical examination suggests specific underlying conditions 4, 2

4. Topical doxepin limitations: If used, should be limited to 8 days and 10% of body surface area (maximum 12g daily) due to risk of allergic contact dermatitis 1

5. Monitoring disease control: Use validated tools like UCT and UAS7 to objectively assess treatment response rather than subjective reporting alone 1