What is the management of urticaria (hives) after COVID-19 vaccination?

Management of Urticaria After COVID-19 Vaccination

Urticaria after COVID-19 vaccination can be effectively managed with antihistamines, and patients should generally proceed with completing their vaccination series despite experiencing this reaction.

Timing and Presentation

Urticaria following COVID-19 vaccination can present in two main patterns:

• Immediate reactions: Occurring within 4 hours of vaccination
• Delayed reactions: Typically appearing 8-24 hours after vaccination, with some cases occurring up to 24 hours post-vaccination 1

Evaluation and Management

Initial Assessment

• Determine timing of urticaria onset in relation to vaccination
• Assess severity and extent of urticaria (localized vs. generalized)
• Rule out other concerning symptoms suggesting anaphylaxis (respiratory distress, hypotension)

Treatment Approach

1. First-line treatment: H1 antihistamines

   • Standard doses are typically effective for most post-vaccination urticaria 1
   • May continue for several days until resolution

2. For persistent or severe symptoms:

   • Increase antihistamine dosing (up to 4× standard dose)
   • Short course of oral corticosteroids may be considered for severe cases 2
   • Monitor for resolution (median time to symptom resolution is approximately 4 days) 1

Revaccination Considerations

For Patients with History of Post-Vaccination Urticaria

• Patients can generally receive subsequent doses of COVID-19 vaccines despite experiencing urticaria after previous doses 1, 3
• Pre-medication with antihistamines can be considered before subsequent doses
• Extended observation period (at least 2 hours) is recommended for patients with systemic lupus erythematosus (SLE) and other rheumatologic conditions 2

Risk of Recurrence

• Approximately 40% of patients may experience recurrent delayed urticaria with subsequent doses 1
• Patients should be counseled about this possibility but reassured that these reactions are not life-threatening

Special Populations

Patients with Chronic Spontaneous Urticaria (CSU)

• Most patients with well-controlled CSU (91.88%) do not experience disease exacerbation after vaccination 4
• For those on omalizumab therapy, avoid vaccination during the scheduled 2-month stop period of treatment 4
• Patients experiencing CSU exacerbation can typically manage symptoms with antihistamines 4

Patients on Immunomodulatory Therapies

• No modifications needed for most immunomodulatory medications when receiving COVID-19 vaccination 2
• For specific medications like methotrexate or JAK inhibitors, consider withholding for 1 week after each vaccine dose if disease is well-controlled 2

Important Considerations

• Skin testing for vaccine excipients has not been shown to predict delayed urticarial reactions 1
• Distinguish between immediate allergic reactions (within 4 hours) and delayed urticarial reactions, as management differs
• Urticaria alone, even when immediate, is generally not a contraindication to receiving subsequent doses of the same vaccine 3

Red Flags Requiring Urgent Attention

• Urticaria with angioedema affecting airways
• Signs of anaphylaxis (respiratory distress, hypotension)
• Urticaria with signs of thrombosis (severe headache, visual disturbances, shortness of breath, chest pain, leg swelling) which could suggest rare vaccine-induced thrombotic thrombocytopenia 5

By following these guidelines, most cases of post-COVID-19 vaccination urticaria can be effectively managed while allowing patients to complete their vaccination series.