What is the initial treatment plan for urticaria (hives) rash?

Initial Treatment Plan for Urticaria Rash

Second-generation non-sedating H1 antihistamines are the first-line treatment for urticaria, with options including cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine. 1, 2, 3

First-Line Treatment Approach

• Start with a standard dose of a second-generation non-sedating H1 antihistamine such as cetirizine or loratadine 1, 2
• Cetirizine has the shortest time to attain maximum concentration, which may be advantageous when rapid relief is needed 1, 3
• Patients should be offered at least two different non-sedating antihistamines as responses and tolerance vary between individuals 1, 2, 3
• For inadequate symptom control after 2-4 weeks, the dose can be increased up to 4 times the standard dose when potential benefits outweigh risks 1, 2, 3

Adjunctive Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 1, 2, 3
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1, 2, 3
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 2
• First-generation antihistamines may be added at night for additional symptom control, but their sedating effects should be considered 2, 3

Treatment Algorithm for Inadequate Response

• If standard dose antihistamine is ineffective after 2-4 weeks, increase to up to 4 times the standard dose 1, 2, 3
• If still inadequate control, add omalizumab 300 mg every 4 weeks (second-line treatment) 1, 2, 3
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 2, 3
• If inadequate response to omalizumab within 6 months, add cyclosporine (third-line treatment) 1, 2, 3

Special Considerations

• Oral corticosteroids should be restricted to short courses (3-10 days) for severe acute exacerbations but should not be used chronically due to cumulative toxicity 2, 3
• For angioedema without wheals, ACE inhibitors should be avoided 1, 3
• In renal impairment: Avoid acrivastine in moderate renal impairment; halve the dose of cetirizine and levocetirizine 3
• In hepatic impairment: Avoid mizolastine in significant hepatic impairment 3

Clinical Pitfalls to Avoid

• Avoid prolonged use of first-generation antihistamines as primary therapy due to their sedative and anticholinergic effects 4, 5
• Do not rely on antihistamines alone for anaphylaxis; epinephrine is the first-line treatment in such cases 6
• Recent evidence suggests that adding corticosteroids to antihistamines for acute urticaria may not provide additional benefit 7
• Avoid chronic use of oral corticosteroids due to their significant side effect profile 2, 8