What is the treatment for urticaria?

Treatment of Urticaria

The first-line treatment for urticaria is second-generation H1 antihistamines, which can be increased up to 4 times the standard dose if symptoms persist. 1

Step-wise Treatment Approach

First-line Treatment

• Second-generation H1 antihistamines at standard doses:
  • Cetirizine 10 mg/day
  • Loratadine 10 mg/day
  • Fexofenadine 180 mg/day
  • Desloratadine 5 mg/day 1

Second-line Treatment

• Increase dose of second-generation H1 antihistamines 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)

• Omalizumab 300 mg subcutaneously every 4 weeks
  • Response rate: 65-87% of patients 1, 2
• Cyclosporine up to 5 mg/kg body weight
  • Requires monitoring of blood pressure and renal function every 6 weeks 1

Important Considerations

Avoid First-generation Antihistamines

• First-generation antihistamines (e.g., diphenhydramine, hydroxyzine) should be avoided due to:
  • Sedating effects
  • Anticholinergic effects
  • Particularly problematic in elderly patients 1, 3

Corticosteroid Use

• Avoid prolonged use of corticosteroids due to adverse effects
• Reserve for acute exacerbations in short courses (3-10 days)
• If necessary, use prednisone 0.5-1 mg/kg/day until symptoms resolve to grade 1 1, 3
• Recent evidence suggests adding corticosteroids to antihistamines may not improve symptoms in acute urticaria 4

Monitoring and Assessment

• Evaluate response to treatment after 2 weeks before modifying therapy
• Use validated tools to monitor disease activity and treatment response:
  • 7-Day Urticaria Activity Score (UAS7)
  • Urticaria Control Test (UCT) 1

Special Situations

Anaphylaxis Management

If urticaria is accompanied by signs of anaphylaxis:

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

Chronic Spontaneous Urticaria (CSU)

• Diagnosis confirmed when wheals and/or angioedema persist for >6 weeks
• Follow the same treatment algorithm as above
• Omalizumab is particularly effective for CSU that is refractory to antihistamines 1, 2

Pediatric Patients

• Use age-appropriate dosing of second-generation H1-antihistamines
• Weight-based dosing is essential
• Educate patients with anaphylaxis risk regarding signs, symptoms, and treatment
• Consider prescription of epinephrine autoinjector if appropriate 1

Common Pitfalls to Avoid

• Using first-generation antihistamines as first-line therapy
• Taking antihistamines only after hives appear (should be used regularly) 5
• Long-term corticosteroid use
• Failing to increase antihistamine dose before moving to other therapies
• Not identifying and avoiding specific triggers when possible 1
• Inadequate follow-up to assess treatment response

By following this evidence-based approach, most patients with urticaria can achieve symptom control and improved quality of life.