What is the recommended treatment for urticaria?

Treatment of Urticaria

Second-generation non-sedating H1 antihistamines are the mainstay of therapy for both acute and chronic urticaria, with dose escalation up to 4 times the standard dose recommended for inadequate symptom control. 1, 2, 3

First-Line Treatment: Antihistamines

• Second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine) should be used as first-line therapy for both acute and chronic urticaria 1, 3
• Patients should be offered at least two different non-sedating antihistamines, as responses and tolerance vary between individuals 1, 2
• Antihistamines should be used on a regular basis, not only after hives occur 4
• For daytime use, newer, less sedating antihistamines are preferred to avoid sedation and impairment 5
• First-generation antihistamines should generally be avoided due to sedation, though they may be added at night for additional symptom control in some cases 2, 3

Dose Escalation

• For inadequate symptom control, increasing the dose up to 4 times the standard dose is recommended when potential benefits outweigh risks 1, 2
• This higher-than-standard dosing is commonly required for chronic urticaria compared to allergic rhinitis 5

Second-Line Treatment: Omalizumab

• Omalizumab (anti-IgE monoclonal antibody) is recommended for chronic spontaneous urticaria unresponsive to high-dose antihistamines 1, 2
• The standard starting dose is 300 mg every 4 weeks 1, 3
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 2
• Omalizumab is effective in approximately 70% of antihistamine-refractory patients 5

Third-Line Treatment: Cyclosporine

• Cyclosporine is recommended for patients who do not respond to high-dose antihistamines and omalizumab 1, 2
• Effective in about two-thirds of patients with severe autoimmune urticaria at 4 mg/kg daily for up to 2 months 1, 3
• Regular monitoring of blood pressure and renal function (every 6 weeks) is required due to potential side effects 1, 2

Role of Corticosteroids

• Oral corticosteroids should be restricted to short courses (3-10 days) for severe acute urticaria or exacerbations 3, 5
• Most patients respond to doses equivalent to 40 mg of prednisone daily 4
• Corticosteroids should not be employed chronically due to cumulative toxicity that is dose and time dependent 5
• Recent evidence suggests that adding corticosteroids to antihistamines may not improve symptoms of acute urticaria compared to antihistamine alone 6

Special Considerations

General Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 1, 2
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1, 3
• ACE inhibitors should be avoided in patients with angioedema without wheals 1, 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1

Special Populations

• In renal impairment: Avoid acrivastine in moderate renal impairment; halve the dose of cetirizine, levocetirizine, and hydroxyzine 1, 3
• In hepatic impairment: Avoid mizolastine in significant hepatic impairment; avoid alimemazine, chlorphenamine, and hydroxyzine in severe liver disease 1, 3
• In pregnancy: Avoid antihistamines if possible, especially during the first trimester; choose chlorphenamine if necessary due to its long safety record 1, 3

Management of Anaphylaxis

• For urticaria with signs of anaphylaxis, epinephrine is the first-line treatment, followed by antihistamines and corticosteroids 2, 7

Treatment Algorithm

1. Start with standard dose of second-generation H1 antihistamine 1, 2
2. If inadequate control after 2-4 weeks, increase antihistamine dose up to 4x standard dose 1, 3
3. If still inadequate control after 2-4 weeks at maximum antihistamine dose, add omalizumab 300 mg every 4 weeks 1, 2
4. If inadequate response to omalizumab within 6 months, consider cyclosporine 1, 3
5. For severe acute exacerbations at any point, consider short course of oral corticosteroids 3, 5

Prognosis

• About 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 3
• Patients with wheals and angioedema have a poorer outlook, with over 50% still having active disease after 5 years 3
• More than half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 8