Prednisone Dosing for Acute Urticaria (Hives)
For acute allergic urticaria, prednisone 20 mg orally every 12 hours (40 mg total daily) for 4 days is the evidence-based dose that provides superior symptom relief and faster resolution compared to antihistamines alone. 1
Recommended Dosing Protocol
Start with prednisone 20 mg orally twice daily (total 40 mg/day) for 3-4 days, combined with antihistamines like hydroxyzine 25 mg every 4-8 hours as needed for breakthrough pruritus. 1 This short burst approach has been proven effective in a randomized controlled trial specifically for acute urticaria, showing significantly lower itch scores at both 2-day and 5-day follow-up compared to antihistamines alone (P < .0001). 1
- The effect is typically appreciable within 24 hours of the first dose. 2
- This 4-day burst regimen requires no taper due to its short duration. 1
- No adverse effects were noted with this short-course protocol. 1
Alternative Dosing for Antihistamine-Resistant Cases
If the initial antihistamine response is inadequate, prednisone 25 mg daily for 3 days is an alternative evidence-based approach that induced remission in nearly 50% of patients with chronic urticaria resistant to antihistamines. 2
- For patients who respond temporarily but relapse, a second identical course can induce remission in an additional 9% of cases. 2
- Less than 15% of patients fail to respond to this treatment approach. 2
Important Clinical Considerations
The 5 mg or 10 mg daily doses mentioned in your question are insufficient for acute urticaria management. The evidence consistently supports higher doses in the 20-40 mg/day range for acute allergic reactions. 3, 1
- For chronic urticaria requiring longer-term control, the goal is to reach an effective low, alternate-day dose followed by discontinuation, but most patients initially respond to doses equivalent to 40 mg prednisone daily. 3
- Avoid courses shorter than the recommended 3-4 days, as inadequate duration can lead to rebound symptoms. 4
Concurrent Antihistamine Therapy
Always combine corticosteroids with H1-antihistamines on a regular scheduled basis, not just as-needed after hives appear. 3
- Diphenhydramine 50 mg can be given initially for rapid effect. 1
- Maintenance with hydroxyzine 25 mg every 4-8 hours or non-sedating antihistamines like cetirizine/loratadine 10 mg daily for daytime use. 5, 3
When to Avoid or Use Caution
Exclude patients with active peptic ulcer disease or uncontrolled diabetes from short-course corticosteroid therapy. 1 However, the 4-day burst protocol carries minimal risk of typical corticosteroid complications given its brief duration. 1