Treatment of Hives (Urticaria)
Second-generation non-sedating H1 antihistamines are the first-line treatment for hives (urticaria), with the option to increase the dose up to four times the standard dose for inadequate symptom control. 1
Stepwise Treatment Algorithm
First-Line Treatment: Antihistamines
- Start with standard doses of second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, mizolastine) 1, 2
- Patients should be offered at least two different non-sedating antihistamines, as responses and tolerance vary between individuals 1, 3
- For inadequate symptom control, increase the dose up to 4 times the standard dose 1, 4
- First-generation antihistamines should generally be avoided due to sedation effects 3
- Antihistamines should be used on a regular basis, not only after hives occur 5
Second-Line Treatment: Omalizumab
- For urticaria unresponsive to high-dose antihistamines, omalizumab (anti-IgE monoclonal antibody) is recommended 6, 7
- Start with 300 mg every 4 weeks, with the option to increase up to 600 mg every 14 days in patients with insufficient response 6
- Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 6
- Omalizumab is particularly effective for recurrent anaphylaxis and skin symptoms 6
Third-Line Treatment: Cyclosporine
- For patients who do not respond to high-dose antihistamines and omalizumab 6, 7
- 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 6
- Cyclosporine can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune chronic spontaneous urticaria 7
Management of Anaphylaxis
- For urticaria with signs of anaphylaxis (hypotension, laryngeal edema, vasomotor collapse, oxygen desaturation, seizures), epinephrine is the first-line treatment 6
- Systemic hives with no organ involvement can be managed with antihistamines alone 6
- After epinephrine administration for anaphylaxis, antihistamines and corticosteroids can be added as required 6, 8
Adjunctive Treatments
- Short courses of systemic corticosteroids (e.g., prednisone) may be used for severe flares until hives resolve 3, 5
- Most patients respond to doses equivalent to 40 mg of prednisone daily, with the goal of quickly reaching an effective low, alternate-day dose followed by discontinuation 5
- Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 3
Special Considerations
Renal Impairment
- Avoid acrivastine in moderate renal impairment 1
- Halve the dose of cetirizine, levocetirizine, and hydroxyzine in moderate renal impairment 1
- Cetirizine, levocetirizine, and alimemazine should be avoided in severe renal impairment 1
Hepatic Impairment
- Avoid mizolastine in significant hepatic impairment 1
- Avoid alimemazine, chlorphenamine, and hydroxyzine in severe liver disease 1
General Measures
- Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 1, 3
- NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1
- ACE inhibitors should be avoided in patients with angioedema without weals 1