Over-the-Counter Antihistamines for Urticaria
For a patient with urticaria seeking only over-the-counter treatment, recommend second-generation non-sedating H1 antihistamines—specifically cetirizine, loratadine, or fexofenadine—as first-line therapy, available without prescription. 1, 2
Specific OTC Medication Options
The following second-generation antihistamines are available over-the-counter and represent the definitive first-line treatment for urticaria:
- Cetirizine 10 mg daily is available OTC and reaches maximum concentration fastest, making it advantageous when rapid symptom relief is needed 1, 3
- Loratadine 10 mg daily (or 5 mg for children) is available OTC and represents an equally effective alternative 2, 4
- Fexofenadine is available OTC and should be offered as another option, as individual responses and tolerance vary significantly between antihistamines 1, 2
Dosing Strategy for OTC Use
- Start with the standard labeled dose (cetirizine 10 mg once daily or loratadine 10 mg once daily) taken regularly, not just when hives appear 1, 2, 5
- If symptoms persist after 2-4 weeks on standard dosing, the dose can be increased up to 4 times the standard dose (e.g., cetirizine 10 mg four times daily) before considering prescription-only therapies 1, 2
- Offer the patient at least two different non-sedating antihistamines to trial, as responses vary significantly between individuals 1, 2
Critical Counseling Points
- Take antihistamines on a regular daily basis, not just after hives occur—this is essential for effective control 5
- Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs (like ibuprofen), and codeine 1, 2
- Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide additional symptomatic relief 2
- Approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 1
When OTC Treatment Is Insufficient
- If high-dose OTC antihistamines (up to 4 times standard dose) fail to control symptoms after 2-4 weeks, the patient will need prescription therapies including omalizumab or cyclosporine 1, 2
- Never use antihistamines in place of epinephrine for anaphylaxis—antihistamines take 30-120 minutes to reach peak concentrations and lack the life-saving vasoconstrictive and bronchodilatory properties of epinephrine 1
Common Pitfalls to Avoid
- Avoid first-generation antihistamines like diphenhydramine (Benadryl) or hydroxyzine for routine use, as they cause marked sedation and anticholinergic effects 6
- Avoid NSAIDs in aspirin-sensitive patients with urticaria, as they can aggravate symptoms 1, 2
- Do not recommend chronic corticosteroid use—oral steroids should be restricted to short 3-10 day courses for severe acute exacerbations only, due to cumulative toxicity 1, 7