What is the treatment for urticaria?

Treatment for Urticaria

The first-line treatment for urticaria is second-generation non-sedating H1 antihistamines, with the option to increase dosage up to four times the standard dose if symptoms are inadequately controlled. 1, 2

First-Line Treatment: Antihistamines

• Second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine) are the mainstay of therapy for both acute and chronic urticaria 2, 1
• Patients should be offered the choice of at least two different non-sedating antihistamines, as responses and tolerance vary between individuals 2
• For inadequate symptom control, increasing the dose up to 4 times the standard dose is recommended when potential benefits outweigh risks 2
• Non-sedating antihistamines are preferred over first-generation sedating antihistamines due to fewer CNS and anticholinergic side effects 3, 2

Second-Line Treatment: Omalizumab

• For chronic spontaneous urticaria unresponsive to high-dose antihistamines, omalizumab (anti-IgE monoclonal antibody) is recommended 2, 4
• Starting dose is 300 mg every 4 weeks, with the option to increase up to 600 mg every 14 days in patients with insufficient response 2
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 2
• Particularly effective in IgE-mediated forms of chronic urticaria 4

Third-Line Treatment: Cyclosporine

• For patients who do not respond to high-dose antihistamines and omalizumab, cyclosporine can be considered 2
• Effective in about two-thirds of patients with severe autoimmune urticaria at 4 mg/kg daily for up to 2 months 2
• Regular monitoring of blood pressure and renal function (every 6 weeks) is required due to potential side effects 2
• Particularly effective in patients with autoimmune chronic spontaneous urticaria 4

Treatment for Specific Types of Urticaria

• Acute urticaria: Short courses of oral corticosteroids (e.g., prednisolone 50 mg daily for 3 days in adults) may help shorten duration, although evidence is mixed 2, 5
• Physical urticarias: For symptomatic dermatographism, combination of an antihistamine and an H2 antagonist may be effective 6
• Urticarial vasculitis: Short tapering courses of oral steroids over 3-4 weeks may be necessary 2
• Angio-oedema: Intramuscular epinephrine can be life-saving in severe laryngeal angio-oedema and anaphylaxis 2

Special Populations Considerations

Renal Impairment

• Acrivastine should be avoided in moderate renal impairment 2
• Cetirizine, levocetirizine, and hydroxyzine doses should be halved in moderate renal impairment 2
• Cetirizine, levocetirizine, and alimemazine should be avoided in severe renal impairment 2

Hepatic Impairment

• Mizolastine is contraindicated in significant hepatic impairment 2
• Alimemazine, chlorphenamine, and hydroxyzine should be avoided in severe liver disease 2

Pregnancy

• Antihistamines should be avoided if possible, especially during the first trimester 2
• If necessary, chlorphenamine is often chosen due to its long safety record 2
• Loratadine and cetirizine are FDA Pregnancy Category B drugs 2

General Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 2
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 2
• ACE inhibitors should be avoided in patients with angio-oedema without weals 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 2
• Patient education about the generally favorable prognosis for eventual recovery is important 2

Treatment Approach Algorithm

1. Start with standard dose of second-generation H1 antihistamine 2
2. If inadequate control after 2-4 weeks: Increase dose up to 4x standard dose 2
3. If still inadequate control: Add omalizumab (300 mg every 4 weeks) 2
4. If inadequate response to omalizumab within 6 months: Consider cyclosporine 2
5. For patients with complete disease control, consider step-down after at least 3 consecutive months of control, reducing by no more than 1 tablet per month 2