Is hydroxyzine effective for relieving itching from urticaria (hives)?

Hydroxyzine for Itching from Hives

Hydroxyzine is effective for relieving itching from urticaria (hives), with the FDA-approved dosage for adults being 25 mg three to four times daily. 1

Efficacy and Placement in Treatment Algorithm

• Hydroxyzine is an effective first-generation (sedating) antihistamine for managing pruritus due to allergic conditions including chronic urticaria 1
• While effective, hydroxyzine is generally not recommended as first-line monotherapy due to its sedating properties 2, 3
• Second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, mizolastine) are preferred as first-line treatment 3

Recommended Usage of Hydroxyzine for Urticaria

• Hydroxyzine can be used as an adjunct therapy at night (10-50 mg) alongside a daytime non-sedating antihistamine to help patients sleep better 2
• For adults with pruritus due to allergic conditions including urticaria, the FDA-approved dosage is 25 mg three to four times daily 1
• In real-world settings, hydroxyzine has demonstrated significant improvement in pruritus symptoms and quality of life over 12 weeks 4

Comparative Efficacy

• Studies show that hydroxyzine is as effective as newer non-sedating antihistamines like loratadine in reducing urticaria symptoms (43% reduction with loratadine vs. 47% with hydroxyzine) 5
• However, the addition of hydroxyzine at night to daytime non-sedating antihistamines may not provide additional clinical benefit for urticaria control if the H1 receptor is already saturated 2, 6
• A randomized controlled trial found that using a higher dose of a non-sedating antihistamine alone was equally effective as combining it with nighttime hydroxyzine 6

Side Effects and Precautions

• Hydroxyzine causes significantly more sedation than non-sedating antihistamines (40% of hydroxyzine patients reported somnolence/sedation vs. 5% of loratadine patients) 5
• Daytime somnolence may be increased when hydroxyzine is added to a treatment regimen 6
• Hydroxyzine should be avoided in:
  • Severe liver disease due to inappropriate sedating effects 2
  • Early stages of pregnancy (specifically contraindicated) 2
• The dose of hydroxyzine should be halved in patients with moderate renal impairment 2, 3

Combination Therapy

• For patients with refractory urticaria not responding to H1 antihistamines alone, adding an H2 antihistamine (like cimetidine) may be more beneficial than adding hydroxyzine 7
• Studies show that approximately 85% of patients not responding to hydroxyzine alone showed moderate to good improvement when an H2 antagonist was added 8
• Current guidelines suggest that for inadequate symptom control, increasing the dose of a non-sedating antihistamine up to 4 times the standard dose is preferred over adding a sedating antihistamine 3

Key Takeaways

• While hydroxyzine is FDA-approved and effective for urticaria-related itching, modern treatment guidelines favor non-sedating antihistamines as first-line therapy 3, 1
• Hydroxyzine may be most appropriate as an add-on nighttime therapy for patients with sleep disturbance due to pruritus 2
• The main limitation of hydroxyzine is its sedating effect, which can impact daytime functioning 6, 5
• For patients with inadequate response to standard therapy, increasing the dose of non-sedating antihistamines or adding an H2 antagonist may be more beneficial than adding hydroxyzine 3, 8, 7