What is the treatment for itching and hives after intra-articular steroid injections?

Management of Itching and Hives After Intra-articular Steroid Injections

For patients experiencing itching and hives after intra-articular steroid injections, immediate treatment with second-generation antihistamines such as loratadine 10 mg or cetirizine 10 mg is recommended as first-line therapy, with corticosteroids such as hydrocortisone 200 mg reserved for more severe reactions. 1

Understanding the Reaction

• Hypersensitivity reactions to intra-articular corticosteroid injections can present as either immediate (Type I) or delayed (Type IV) reactions, with symptoms including pruritus, urticaria, and in rare cases, anaphylaxis 2, 3
• The reported incidence of systemic reactions to corticosteroid injections ranges from 0.06% to 0.9%, though local reactions are more common 1
• Patients may develop sensitization after previous exposures, with increased risk of reactions in those who have received multiple courses of intra-articular treatments 4

Initial Management of Reactions

Mild to Moderate Reactions (Itching and Hives)

• Stop any ongoing infusion or injection immediately and monitor vital signs 1
• Administer second-generation antihistamines as first-line treatment:
  • Loratadine 10 mg orally or cetirizine 10 mg orally/IV 1
  • Avoid first-generation antihistamines like diphenhydramine as they may exacerbate hypotension and cause sedation 1
• For persistent symptoms, consider corticosteroid administration:
  • Hydrocortisone 200 mg IV for more severe reactions 1
• Monitor the patient for at least 30 minutes after symptom resolution 1

Severe Reactions (Anaphylaxis)

• For signs of anaphylaxis (respiratory distress, hypotension, angioedema):
  • Administer epinephrine immediately (0.3-0.5 mg IM in anterolateral thigh) 3, 5
  • Establish IV access and administer fluids if hypotensive 1
  • Consider albuterol nebulizer for bronchospasm 1
  • Transfer to emergency department for observation 3

Follow-up Care and Prevention

• Document the reaction in detail, including the specific corticosteroid formulation used 2, 6
• Consider allergy testing (skin prick or intradermal) to identify the specific corticosteroid causing the reaction and potential alternatives 2, 5
• For patients with confirmed hypersensitivity:
  • Avoid the implicated corticosteroid in future treatments 2, 6
  • Consider alternative corticosteroid formulations that showed negative skin tests 3, 6
  • Maintain injectable epinephrine availability during future procedures 3

Special Considerations

• Risk of reaction appears higher in patients who have received multiple courses of intra-articular treatments 4
• Cross-reactivity between different corticosteroids is possible but variable; some patients may tolerate alternative corticosteroid formulations 6
• Patients with a history of multiple drug allergies or previous reactions to injectable medications should be monitored more closely 1

Alternative Treatment Options

• For patients with confirmed corticosteroid allergy who still require joint pain management:
  • Consider non-steroid alternatives such as hyaluronic acid injections (viscosupplementation) 7, 4
  • Physical therapy and other conservative treatments may be appropriate alternatives 7
  • For refractory cases, consultation with rheumatology or allergy specialists is recommended 7

Key Pitfalls to Avoid

• Do not dismiss mild reactions, as sensitization may lead to more severe reactions with subsequent exposures 5, 4
• Avoid first-generation antihistamines like diphenhydramine for treating reactions as they may worsen hypotension 1
• Never reintroduce a corticosteroid that previously caused a reaction without proper allergy testing and specialist consultation 2, 6
• Always have emergency medications (including epinephrine) available when performing intra-articular injections, especially in patients with previous reactions 3