Are steroids helpful for idiopathic urticaria?

Steroids Are Not Recommended for Idiopathic Urticaria

Steroids are not recommended for the treatment of idiopathic urticaria as they show inefficacy in chronic cases and may actually interfere with antihistamine effectiveness. 1

First-Line Treatment Approach

The recommended treatment algorithm for idiopathic urticaria follows a stepwise approach:

Step 1: Second-generation H1-antihistamines

• Start with standard doses of second-generation H1-antihistamines such as:
  • Fexofenadine 180mg
  • Cetirizine 10mg
  • Loratadine 10mg
  • Desloratadine
  • Bilastine
  • Levocetirizine 2

Step 2: Increase antihistamine dose

• If inadequate response to standard doses, increase up to 4 times the standard dose
  • Example: Fexofenadine 180mg → up to 720mg daily
  • Example: Loratadine 10mg → up to 40mg daily 2

Step 3: Add additional therapies for refractory cases

• Leukotriene receptor antagonists
• Omalizumab (300mg subcutaneously every 4 weeks)
• Cyclosporine (up to 5mg/kg body weight with monitoring) 2

Evidence Against Steroid Use

Research demonstrates several issues with steroid use in idiopathic urticaria:

• A prospective study of 17 patients showed that most cases of chronic urticaria can be managed without oral steroids 1
• After steroid withdrawal, 35% of patients achieved complete remission and 47% had partial remission at 12 months 1
• Evidence suggests steroids may actively interfere with antihistamine effectiveness 1
• The 2007 British Journal of Dermatology guidelines do not recommend routine use of topical steroids for idiopathic urticaria 3

Alternative Treatments for Refractory Cases

For patients with severe urticaria unresponsive to antihistamines:

1. Cyclosporine: Effective in patients with positive autologous serum skin test (ASST)

   • Dosing: Start at 2-5mg/kg/day with gradual reduction
   • Monitoring: Blood pressure and renal function every 6 weeks
   • Potential side effects: Hypertension, hirsutism, gum hypertrophy, renal failure 2, 4, 5

2. Omalizumab:

   • 65-87% of patients respond to therapy
   • Dosing: 300mg subcutaneously every 4 weeks
   • Safety precaution: Monitor for anaphylaxis (can occur with any dose) 2

3. Other options for consideration:

   • Nifedipine (may reduce pruritus and wealing but clinical benefit often disappointing) 3
   • Thyroxine (in euthyroid patients with thyroid autoimmunity) 3
   • Sulfasalazine (caution in aspirin-sensitive patients) 3
   • Tranexamic acid (for idiopathic angioedema without weals) 3

Monitoring and Follow-up

• Use validated tools like Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control
• Consider treatment successful if complete control is achieved for at least 3 consecutive months
• If stepping down treatment, reduce dose gradually (not more than 1 tablet per month) 2

Important Caveats

• Topical steroids have shown limited evidence for effectiveness in chronic idiopathic urticaria 6
• While some patients showed immediate response to potent topical steroids under occlusion, effects were short-lived (average relapse after 3 weeks) 7
• If urticaria is accompanied by signs of anaphylaxis, epinephrine is the first-line treatment, not steroids 2
• Patients with delayed pressure urticaria do not appear to benefit from oral steroids 1

In conclusion, the evidence strongly suggests avoiding steroids in idiopathic urticaria and instead following a stepwise approach with antihistamines and other targeted therapies for refractory cases.