Prednisolone for Urticaria
For acute urticaria in adults, prednisolone 50 mg daily for 3 days is the recommended dose, though lower doses are often effective. 1
Acute Urticaria
Standard Dosing
- Prednisolone 50 mg daily for 3 days is the guideline-recommended regimen for acute urticaria in adults 1
- Lower doses are frequently effective and should be considered to minimize corticosteroid exposure 1
- The FDA label indicates that initial doses may range from 5-60 mg per day depending on disease severity, with dosing individualized based on response 2
When to Use Corticosteroids
- Oral corticosteroids may shorten the duration of acute urticaria but should be reserved for cases not adequately controlled with antihistamines 1
- For severe acute urticaria (>30% body surface area), prednisone 0.5-1 mg/kg/day until hives resolve is recommended 3
- Short courses of 3-10 days are appropriate for severe acute exacerbations 4
Route of Administration
- Oral prednisolone is preferred for most cases 1
- Parenteral hydrocortisone is reserved as an adjunct for severe laryngeal edema and anaphylaxis, though its action is delayed 1
- High-concentration liquid prednisolone (100 mg or >250 mg) achieves symptom control comparable to intravenous therapy, with remission of at least 50% of symptoms in less than 30 minutes 5
Chronic Urticaria
Critical Restriction
- Long-term oral corticosteroids should NOT be used in chronic urticaria (Strength of recommendation A) except in very selected cases under regular specialist supervision 1
- This is a firm contraindication due to cumulative toxicity and poor risk-benefit ratio 4
Limited Indications for Longer Courses
- Short tapering courses over 3-4 weeks may be necessary for:
- These represent exceptions requiring specialist oversight 1
Autoimmune Urticaria Exception
- For ASST-positive autoimmune urticaria refractory to antihistamines, low-dose prednisolone therapy (starting at 40 mg/day, then gradually tapered) administered for an average of 3.6 months achieved complete long-lasting response in 83.3% of patients 6
- This represents a specific subset where longer corticosteroid courses may be justified 6
Treatment Algorithm
Step 1: Antihistamines First
- Second-generation non-sedating H1 antihistamines are first-line therapy 3, 7, 4
- Increase dose up to 4 times standard if inadequate response 3, 7, 4
Step 2: Consider Corticosteroids
- Add prednisolone 50 mg daily for 3 days for acute urticaria not responding to antihistamines 1
- For severe cases, use prednisone 0.5-1 mg/kg/day 3
- Most patients respond to doses equivalent to 40 mg prednisone daily 8
Step 3: Taper and Discontinue
- After symptom control (usually 7-10 days), gradually decrease the dose 6
- Withdraw gradually rather than abruptly after long-term therapy 2
- Restrict total duration to 3-10 days for acute urticaria 4
Common Pitfalls to Avoid
Do Not Use Long-Term for Chronic Urticaria
- The most critical error is using chronic corticosteroids for chronic spontaneous urticaria 1
- Instead, escalate to omalizumab or cyclosporine for antihistamine-refractory chronic urticaria 7, 4
Do Not Delay Alternative Therapies
- If corticosteroids are needed beyond a short course, this indicates treatment failure requiring specialist referral and alternative immunomodulating therapies 1, 9
- Cyclosporine 4 mg/kg daily for up to 2 months is effective in two-thirds of severe autoimmune urticaria cases unresponsive to antihistamines 1
Recognize Angioedema Complications
- Assess for airway compromise in cases with angioedema 3
- Consider epinephrine for severe symptoms affecting breathing 3
- Intramuscular epinephrine (500 µg for adults) can be life-saving in severe laryngeal angioedema 1
Special Populations
Pediatric Dosing
- Initial dose range: 0.14-2 mg/kg/day in three or four divided doses 2
- For asthma exacerbations: 1-2 mg/kg/day in single or divided doses for 3-10 days 2
Pregnancy
- Avoid corticosteroids if possible, especially in first trimester 1
- If necessary, use lowest effective dose for shortest duration 1