What is the treatment for acute urticaria (hives) with sudden onset?

Treatment for Acute Urticaria (Hives) with Sudden Onset

Second-generation non-sedating H1 antihistamines are the first-line treatment for acute 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, mizolastine) should be used as initial therapy due to their favorable efficacy and safety profile 1, 2
• For rapid relief, cetirizine may be advantageous as it has the shortest time to attain maximum concentration 3
• If symptom control is inadequate with standard dosing, increase the dose up to 4 times the standard dose when benefits outweigh risks 1, 2, 4
• Try at least two different non-sedating antihistamines as individual responses and tolerance vary between patients 1, 2
• First-generation antihistamines should generally be avoided due to sedation and potential to worsen reactions 1, 5

Adjunctive Treatments for Acute Urticaria

• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief of itching 2, 3
• Short courses of systemic corticosteroids may be considered for severe acute urticaria until symptoms resolve to grade 1, though evidence is mixed 1, 6
• The addition of corticosteroids to antihistamines did not improve symptoms compared to antihistamine alone in two out of three randomized controlled trials 6
• For severe cases with angioedema or signs of anaphylaxis, epinephrine is the first-line treatment 1

Treatment Algorithm for Persistent or Severe Cases

If acute urticaria persists beyond 6 weeks, it becomes classified as chronic urticaria, requiring a stepped approach:

1. Step 1: Standard dose second-generation H1 antihistamine 7
2. Step 2: Increase antihistamine dose up to 4x standard dose if inadequate control 7
3. Step 3: Add omalizumab 300 mg every 4 weeks (can be increased up to 600 mg every 14 days in patients with insufficient response) 7
4. Step 4: Consider cyclosporine for patients who don't respond to high-dose antihistamines and omalizumab 7

Important Considerations and Precautions

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 2, 3
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 2, 3
• ACE inhibitors should be avoided in patients with angioedema without wheals 2, 3
• For patients with renal impairment, avoid acrivastine in moderate renal impairment, and halve the dose of cetirizine, levocetirizine, and hydroxyzine 2
• For patients with hepatic impairment, avoid mizolastine in significant hepatic impairment 2

Monitoring and Follow-up

• Most cases of acute urticaria are self-limited and resolve within days to weeks 8
• If symptoms persist beyond 6 weeks, reclassify as chronic urticaria and consider further diagnostic workup 8
• More than half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 8