What steroid injection is recommended for contact urticaria?

Steroid Injection for Contact Urticaria

For contact urticaria requiring steroid injection, intramuscular hydrocortisone 100-500 mg is the recommended treatment, especially for moderate to severe reactions. 1

Treatment Algorithm for Contact Urticaria

First-line Treatment

• Begin with second-generation (non-sedating) H1-antihistamines such as cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine 2
• For inadequate response, increase antihistamine dose up to four times the standard dose 2

Steroid Injection for Moderate to Severe Reactions

• Hydrocortisone 100-500 mg IV/IM is the preferred steroid injection for contact urticaria with moderate symptoms 1
• For severe reactions with hypotension or systemic symptoms, administer hydrocortisone alongside emergency measures 1

Management Based on Severity

Mild Contact Urticaria

• Monitor for ≥15 minutes 1
• Maintain IV normal saline at keep-vein-open rate 1
• Consider H2 antagonist (famotidine 20 mg IV) as adjunctive therapy 1

Moderate Contact Urticaria

• Administer hydrocortisone 100-500 mg IV/IM 1
• Add H2 antagonist (famotidine 20 mg IV) 1
• For urticaria: add second-generation antihistamine (loratadine 10 mg PO or cetirizine 10 mg IV/PO) 1

Severe Contact Urticaria/Anaphylaxis

• Immediately administer epinephrine (1 mg/mL) 0.3 mg IM into anterolateral mid-third thigh 1
• Follow with hydrocortisone 100-500 mg IV 1
• Note: Epinephrine is not considered helpful for angioedema caused by C1 inhibitor deficiency 1

Special Considerations

Pediatric Patients

• Adjust steroid dosing based on weight and age 3
• Liquid formulations may be more appropriate for toddlers who cannot swallow tablets 3
• For children 2-5 years, cetirizine is the preferred antihistamine at 2.5 mg once or twice daily 3

Pregnancy

• Avoid all antihistamines if possible, especially during the first trimester 1
• If antihistamine therapy is necessary, chlorphenamine is often chosen due to its long safety record 1
• Short courses of systemic corticosteroids may be necessary in severe cases, but use with caution 1

Hepatic Impairment

• Avoid chlorphenamine and hydroxyzine in severe liver disease due to inappropriate sedating effects 1

Efficacy and Safety

• Short courses of systemic corticosteroids likely improve urticaria activity with a 14-15% absolute difference compared to antihistamines alone 4
• However, systemic corticosteroids also likely increase adverse events in approximately 15% more patients 4
• Long-term oral corticosteroids should not be used in chronic urticaria except in very selected cases under regular specialist supervision 1

Important Cautions

• Be aware of potential allergic reactions to steroid preparations themselves, which can induce hypersensitivity reactions including contact urticaria 5
• Some patients may have allergies to excipients in topical corticosteroid formulations, such as glycols, which can cause severe contact urticaria with systemic involvement 6
• First-generation antihistamines (e.g., diphenhydramine) and vasopressors should be avoided for minor infusion reactions, as these medications have the potential to worsen reactions 1