What is the best approach to treating urticaria?

Treatment Approach for Urticaria

The best approach to treating urticaria is to start with second-generation H1 antihistamines at standard doses, progressively increasing up to 4 times the dose if necessary, before considering other therapies such as omalizumab or cyclosporine. 1

Stepwise Treatment Algorithm

First-Line Treatment

• Begin with standard doses of second-generation H1 antihistamines:
  • Cetirizine 10 mg/day
  • Loratadine 10 mg/day
  • Fexofenadine 180 mg/day
  • Desloratadine 5 mg/day 1

Second-Line Treatment

• If inadequate response after 2 weeks, increase antihistamine dose up to 4 times the standard dose:
  • Cetirizine up to 40 mg/day
  • Loratadine up to 40 mg/day
  • Fexofenadine up to 720 mg/day 1

Third-Line Treatment

• For refractory cases, consider:
  • Omalizumab 300mg subcutaneously every 4 weeks (65-87% response rate)
  • Cyclosporine (up to 5mg/kg body weight) with blood pressure and renal function monitoring every 6 weeks 1
  • Leukotriene receptor antagonists as adjunctive therapy 1, 2

Assessment and Monitoring

• Evaluate treatment response after 2 weeks using validated tools:
  • Urticaria Control Test (UCT)
  • Urticaria Activity Score (UAS7) 1
• Refer to secondary care if:
  • Diagnostic uncertainty exists
  • Primary care management fails to relieve symptoms 1

Special Considerations

Acute vs. Chronic Urticaria

• Acute urticaria (≤6 weeks) is often triggered by:
  • Viral infections
  • Allergic reactions to foods and drugs
  • Contact with chemicals and irritants
  • Physical stimuli 2, 3
• Chronic urticaria (>6 weeks) is idiopathic in 80-90% of cases 2
  • About one-third of children with chronic urticaria have autoantibodies against IgE receptors ("autoimmune" urticaria) 4
  • Resolution or improvement occurs in more than half of chronic urticaria patients within a year 2

Pediatric Considerations

• Use age-appropriate, weight-based dosing of second-generation H1-antihistamines
• Food allergies are a common cause in infants and may require allergist evaluation 1
• Patients at risk for anaphylaxis should be educated about signs, symptoms, and treatment, with prescription of epinephrine autoinjector if appropriate 1

Corticosteroid Use

• Avoid prolonged use due to adverse effects
• Reserve for acute exacerbations in short courses (3-10 days)
• If necessary, use prednisone at 0.5-1 mg/kg/day until symptoms resolve to grade 1 1

Anaphylaxis Management

• For urticaria with signs of anaphylaxis:
  • Administer epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment
  • Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV)
  • Seek immediate emergency medical attention 1

Common Pitfalls to Avoid

• Using first-generation antihistamines, especially in elderly patients, due to sedating and anticholinergic effects 1
• Prolonged corticosteroid use, which can cause glucose metabolism alterations, increased appetite, fluid retention, weight gain, facial flushing, mood changes, and hypertension 1
• Inadequate dose escalation of antihistamines before moving to more advanced therapies 1, 2
• Extensive laboratory workup for chronic urticaria when history and physical examination don't suggest specific underlying conditions 2

By following this stepwise approach and avoiding common pitfalls, most patients with urticaria can achieve significant symptom control and improved quality of life.