Treatment of Not Severe Hives
For not severe hives (mild urticaria), start with a standard-dose second-generation non-sedating H1 antihistamine such as fexofenadine 60 mg twice daily, cetirizine 10 mg daily, or loratadine 10 mg daily as first-line therapy. 1, 2, 3
First-Line Treatment: Second-Generation Antihistamines
Second-generation non-sedating H1 antihistamines are the mainstay of therapy for both acute and chronic urticaria, with multiple options available including fexofenadine, cetirizine, loratadine, desloratadine, levocetirizine, and mizolastine. 4, 2, 5
Offer patients a choice of at least two different non-sedating antihistamines, as individual responses and tolerance vary significantly between agents. 1, 2
Fexofenadine (Allegra) 60 mg twice daily is an appropriate choice for not severe hives, as it is non-sedating and well-tolerated. 4
Cetirizine has the shortest time to maximum concentration, which may provide more rapid symptom relief if speed of onset is clinically important, though it may be mildly sedating at standard doses. 4, 1
Dose Escalation Strategy if Standard Dosing Fails
If symptoms persist after 2-4 weeks on standard dosing, increase the antihistamine dose up to 4 times the standard dose before considering additional therapies. 1, 2
This dose escalation approach is recommended when potential benefits outweigh risks and should be attempted before moving to second-line agents. 2, 3
Adjunctive Measures for Symptom Control
Identify and minimize nonspecific aggravating factors including overheating, stress, alcohol, and medications that can worsen urticaria such as aspirin, NSAIDs, and codeine. 4, 1, 2
Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide additional symptomatic relief. 4, 3
First-generation antihistamines may be added at night if additional symptom control is needed, particularly to help with sleep disruption from itching. 2
Important Caveats and Pitfalls
Antihistamines should not be used in place of epinephrine if the patient develops severe symptoms such as diffuse hives, shortness of breath, respiratory symptoms, or obstructive swelling affecting breathing. 4
Systemic hives with organ involvement (airway, gastrointestinal, neurologic, or cardiovascular symptoms) requires epinephrine, not just antihistamines. 4
Avoid NSAIDs in aspirin-sensitive patients with urticaria due to risk of cross-reactions related to cyclooxygenase inhibition. 4, 2
ACE inhibitors should be used with caution if angioedema is present alongside urticaria. 4, 2
When to Consider Corticosteroids
- Oral corticosteroids should be restricted to short courses (3-10 days) for severe acute exacerbations only, not for mild/not severe hives, due to cumulative toxicity with prolonged use. 1
Prognosis and Patient Education
Approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months, though the prognosis is worse for those with both wheals and angioedema. 1, 2
Provide clear written information explaining that while a specific cause is unlikely to be found in most cases, the prognosis for eventual recovery is excellent. 4