What is the first line treatment for urticaria on bilateral arms?

First-Line Treatment for Urticaria on Bilateral Arms

Start with a second-generation non-sedating H1 antihistamine (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, or mizolastine) at standard dosing, and if symptoms are not adequately controlled within days, increase the dose up to 4 times the standard dose. 1, 2, 3

Treatment Algorithm

Step 1: Initial Antihistamine Therapy

• Begin with a second-generation H1 antihistamine at standard dosing as these are the mainstay of therapy for both acute and chronic urticaria 3, 4
• Offer patients at least two different non-sedating antihistamines to trial, as individual responses and tolerance vary significantly between agents 2, 3
• Cetirizine may be preferred when rapid relief is needed, as it has the shortest time to maximum concentration 2
• Use antihistamines on a regular scheduled basis, not just after hives appear 5

Step 2: Dose Escalation (If Inadequate Response)

• Increase the antihistamine dose up to 4 times the standard dose when potential benefits outweigh risks 1, 2, 3
• This dose escalation has become common practice and is recommended by international guidelines, though it exceeds manufacturer's licensed recommendations 1
• Consider adding a first-generation antihistamine (such as hydroxyzine) at night for additional symptom control and to help with sleep 3, 4

Step 3: Second-Line Treatment (If High-Dose Antihistamines Fail)

• Add omalizumab 300 mg subcutaneously every 4 weeks if symptoms remain inadequately controlled (less than 50% improvement) on high-dose antihistamines 1, 4, 6
• Allow up to 6 months for patients to respond to omalizumab before considering it a treatment failure 1, 2
• In patients with insufficient response, updosing can be considered by shortening the interval and/or increasing the dosage up to 600 mg every 14 days 1, 4

Step 4: Third-Line Treatment (If Omalizumab Fails)

• Use cyclosporine 4 mg/kg daily for patients who do not respond to high-dose antihistamines and omalizumab 1, 2, 4
• Cyclosporine is effective in approximately 54-73% of patients, particularly those with autoimmune urticaria 6, 7
• Monitor blood pressure and renal function every 6 weeks due to risks of hypertension and kidney dysfunction 1, 4

Adjunctive Measures

Identify and Avoid Triggers

• Look for and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 2, 3, 4
• NSAIDs must be avoided in aspirin-sensitive patients with urticaria 2, 3
• ACE inhibitors should be avoided if there is any angioedema component 2, 3

Symptomatic Relief

• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide additional symptomatic relief 2, 4

Important Caveats

What NOT to Do

• Do not use corticosteroids as routine therapy - restrict oral corticosteroids to short courses (3-10 days) only for severe acute urticaria or severe exacerbations 1, 3, 6
• Do not use H2 antihistamines or leukotriene antagonists - they add little benefit and literature does not support significant efficacy 6
• Do not delay antihistamine treatment - approximately 40% of patients respond well to antihistamines alone 1, 7

Special Population Considerations

• In renal impairment: Avoid acrivastine in moderate renal impairment; halve the dose of cetirizine, levocetirizine, and hydroxyzine 3, 4
• In hepatic impairment: Avoid mizolastine in significant hepatic impairment 3, 4
• In pregnancy: Avoid antihistamines if possible, especially during first trimester; if necessary, choose chlorphenamine due to its long safety record 3, 4

Prognosis Context

• About 50% of patients with wheals alone will be clear by 6 months 3, 4
• Patients with both wheals and angioedema have a poorer outlook, with over 50% still having active disease after 5 years 1, 3
• At least 30% of patients have insufficient response to omalizumab, particularly those with IgG-mediated autoimmune urticaria 7