What is the treatment for urticaria (hives) in children?

Treatment of Urticaria (Hives) in Children

H1 antihistamines are the mainstay of treatment for urticaria in children, with second-generation non-sedating antihistamines being the first-line therapy. 1

First-Line Treatment

• Second-generation H1 antihistamines (non-sedating) are the cornerstone of urticaria management in children due to their efficacy in controlling symptoms with minimal side effects 1, 2

  • Options include cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine 1
  • These medications should be offered as the initial treatment for all children with urticaria 1

• For children who don't respond adequately to standard doses, increasing the dose of second-generation H1 antihistamines above the manufacturer's licensed recommendation may be considered when benefits outweigh risks 1

Second-Line and Adjunctive Treatments

• For cases resistant to standard doses of second-generation antihistamines, consider these approaches:

  • Combination therapy with H1 and H2 antihistamines (such as ranitidine or famotidine) can be effective for controlling severe pruritus and wheal formation 1
  • Addition of a sedating antihistamine (such as diphenhydramine or hydroxyzine) at night can help with sleep disruption from pruritus 1
  • Leukotriene receptor antagonists (e.g., montelukast) may be added as adjunctive therapy for resistant cases 1, 2

• Short courses of oral corticosteroids should be restricted to severe acute urticaria or angioedema affecting the mouth 1, 3

  • The evidence for adding corticosteroids to antihistamines in acute urticaria is mixed, with most studies showing no additional benefit 3

Management Considerations

• Identify and avoid triggering factors when possible 1, 4

  • Common triggers include hot temperatures, tight clothing, stress/anxiety, and certain medications (especially NSAIDs and aspirin) 1, 4
  • In cases of physical urticaria, identifying the specific physical stimulus allows for lifestyle modifications 1

• Cooling antipruritic lotions, such as calamine or 1% menthol in aqueous cream, can provide symptomatic relief 1

• For urticaria associated with mastocytosis, temperature control is particularly important as mast cells can be activated by hot and cold temperatures 1

Special Considerations

• Duration of individual wheals is diagnostically important:

  • Ordinary urticaria wheals typically last 2-24 hours 1
  • Physical urticaria wheals usually resolve within an hour (except delayed pressure urticaria) 1
  • Wheals lasting longer than 24 hours may suggest urticarial vasculitis and warrant skin biopsy 1

• Most cases of acute urticaria resolve within 6 months, but those with both wheals and angioedema may have a more prolonged course 1

Treatment-Resistant Cases

• For chronic urticaria unresponsive to optimal antihistamine therapy, referral to a specialist may be necessary for consideration of:

  • Omalizumab (anti-IgE antibody) for antihistamine-refractory cases 5
  • Cyclosporine for severe, refractory cases (though this carries more significant side effects) 5, 6

• Immunomodulating therapies should be restricted to patients with disabling disease who have not responded to conventional treatments 1

Pitfalls and Caveats

• Avoid first-generation H1 antihistamines as first-line therapy due to their sedative effects, which can impact school performance and cognitive function 1
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria due to risk of cross-reactions 1
• Extensive laboratory workup is unnecessary for most cases of urticaria unless specific underlying conditions are suggested by history or physical examination 2
• Remember that chronic urticaria is idiopathic in 80-90% of cases, so focusing on symptom management rather than extensive testing for causes is often more beneficial 2