What is the treatment for intermittent hives?

Treatment for Intermittent Hives

Second-generation H1 antihistamines are the first-line treatment for intermittent hives, with the option to increase the dose up to 4 times the standard dose if symptoms persist. 1

First-Line Treatment

• Start with standard doses of second-generation (non-sedating) H1 antihistamines:
  • Cetirizine 10 mg/day
  • Loratadine 10 mg/day
  • Fexofenadine 180 mg/day
  • Desloratadine 5 mg/day 1

Important: Antihistamines should be taken regularly, not just when hives appear, to maintain consistent symptom control 2

Step-Up Approach for Persistent Symptoms

If standard doses are ineffective after 2 weeks:

Step 1: Increase antihistamine dose

• Increase to up to 4 times the standard dose of the second-generation antihistamine 1
• Example: Cetirizine 10 mg four times daily or 40 mg once daily

Step 2: Add additional therapies

If symptoms persist despite high-dose antihistamines:

• Consider adding leukotriene receptor antagonists 1
• Consider omalizumab (Xolair) for chronic spontaneous urticaria (CSU) that remains symptomatic despite H1 antihistamine treatment 3
  • Recommended dosage: 300 mg subcutaneously every 4 weeks
  • Response rate: 65-87% of patients 1

Corticosteroid Use

• Avoid prolonged use of systemic corticosteroids due to adverse effects 1
• Reserve for acute severe exacerbations only
• Short courses (3-10 days) of prednisone 0.5-1 mg/kg/day may be used until symptoms resolve to grade 1 1

Special Considerations

Anaphylaxis Management

If hives are accompanied by signs of anaphylaxis:

• Administer epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment 1
• Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV) 1
• Seek immediate emergency medical attention 1, 3

Monitoring Treatment Response

• Evaluate response after 2 weeks before modifying therapy 1
• Use validated tools such as Urticaria Activity Score (UAS7) and Urticaria Control Test (UCT) to monitor disease control 1

Cautions and Contraindications

• Avoid first-generation antihistamines due to sedating and anticholinergic effects, especially in elderly patients 1
• Be aware that omalizumab carries a risk of anaphylaxis, which can occur after any dose, even in patients who have previously tolerated the medication 3
• Patients receiving omalizumab should be observed for an appropriate period after administration and educated about signs and symptoms of anaphylaxis 3

When to Refer to Specialist Care

• If no response to increased doses of antihistamines after 2-4 weeks
• If diagnostic uncertainty exists
• If symptoms are severe or associated with systemic manifestations
• For consideration of omalizumab or other advanced therapies 1

Remember that while intermittent hives often respond well to antihistamines, persistent symptoms may indicate chronic urticaria, which might require more aggressive management and further diagnostic evaluation.