What is the treatment for urticaria?

Treatment of Urticaria

Second-generation non-sedating H1 antihistamines are the first-line treatment for urticaria, with doses that can be increased up to four times the standard dose for inadequate symptom control. 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 1
• Patients should be offered at least two different non-sedating antihistamines as responses and tolerance vary between individuals 3, 1
• For inadequate symptom control, increasing the dose up to 4 times the standard dose is recommended when potential benefits outweigh risks 1, 2, 4
• Cetirizine has the shortest time to attain maximum concentration, which may be advantageous when rapid relief is needed 3
• First-generation antihistamines should generally be avoided due to sedation and anticholinergic effects 2, 5

Second-Line Treatment: Omalizumab

• For urticaria unresponsive to high-dose antihistamines, omalizumab (anti-IgE monoclonal antibody) is recommended 1, 2
• The standard 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 1, 2
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 2

Third-Line Treatment: Cyclosporine

• For patients who do not respond to high-dose antihistamines and omalizumab, cyclosporine is recommended 1, 2
• Cyclosporine is effective in about two-thirds of patients with severe autoimmune urticaria at 4 mg/kg daily for up to 2 months 1
• Regular monitoring of blood pressure and renal function (every 6 weeks) is required due to potential side effects 1, 2

Special Considerations

Urticarial Vasculitis

• Lesional skin biopsy is essential to confirm small-vessel vasculitis histologically 3, 6
• A full vasculitis screen, including serum complement assays for C3 and C4, is necessary to distinguish normocomplementemic from hypocomplementemic disease 3, 6
• Systemic corticosteroids may be necessary for short courses in urticarial vasculitis 6

Angioedema Without Wheals

• Serum C4 should be used as an initial screening test for hereditary and acquired C1 inhibitor deficiency 3
• ACE inhibitors should be avoided in patients with angioedema without wheals 3, 2

Medication Adjustments for Special Populations

• In renal impairment: Avoid acrivastine in moderate renal impairment; halve the dose of cetirizine, levocetirizine, and hydroxyzine 1
• In hepatic impairment: Avoid mizolastine in significant hepatic impairment 1
• In pregnancy: Avoid antihistamines if possible, especially during the first trimester; choose chlorphenamine if necessary due to its long safety record 1

General Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 3, 1, 2
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 3, 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 3, 2
• Patient education about the generally favorable prognosis is important, as more than half of patients with chronic urticaria will have resolution or improvement within a year 7

Treatment Algorithm

1. Start with standard dose of second-generation H1 antihistamine 1, 2
2. If inadequate control after 2-4 weeks, increase dose up to 4x standard dose 1, 4
3. If still inadequate control, add omalizumab 300mg every 4 weeks 1, 2
4. If inadequate response to omalizumab within 6 months, consider cyclosporine 1, 2
5. For acute severe flares, short courses of systemic corticosteroids may be used 2, 8