Treatment of Recurrent Palpable Rash (Urticaria)
Start with oral second-generation non-sedating H1 antihistamines as first-line therapy, and if inadequate response occurs after trying at least two different agents, escalate the dose up to 4-fold before considering alternative treatments. 1, 2
First-Line Treatment
Begin with second-generation non-sedating H1 antihistamines such as cetirizine, loratadine, or fexofenadine as the initial treatment for recurrent urticaria 1, 2, 3
Trial at least two different non-sedating antihistamines before declaring treatment failure, as individual responses and tolerance vary significantly between agents 1
Cetirizine reaches peak concentration fastest among the second-generation antihistamines, making it advantageous when rapid symptom relief is needed 1
Increase the antihistamine dose up to 4 times the standard dose if standard dosing provides inadequate control before moving to second-line therapy 2, 3
Over 40% of patients achieve good symptom control with antihistamines alone 2
Adjunctive First-Line Measures
Add H2 antihistamines to H1 antihistamines for better urticaria control in some patients, though the benefit is variable 1, 4
Consider adding leukotriene antagonists (montelukast) to H1 antihistamines for poorly controlled urticaria, though evidence for monotherapy is limited 1, 4
Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1
Avoid NSAIDs completely in patients with aspirin-sensitive urticaria 1
Topical Therapy Considerations
Routine topical corticosteroids are NOT recommended for urticaria, as wheals typically last only 2-24 hours and migrate to different locations, making topical treatment impractical 2
Topical steroids may be used only in specific contexts: delayed pressure urticaria with very potent steroids in foam vehicles applied to most affected areas, or under occlusion for 2 weeks in chronic idiopathic urticaria 2
For facial involvement in other dermatologic conditions, low-potency hydrocortisone should be used to avoid skin atrophy 5, 6
Short-Term Corticosteroid Use
Oral corticosteroids (prednisone 0.5-1 mg/kg/day) can shorten the duration of acute urticaria but should not be used long-term in chronic urticaria 1, 7
Short bursts of corticosteroids may be used as adjunctive treatment for severe acute exacerbations 3
Second-Line Treatment
Omalizumab (anti-IgE monoclonal antibody) at 300 mg every 4 weeks is recommended for urticaria unresponsive to high-dose antihistamines 1, 2, 8
This represents the standard second-line approach for antihistamine-refractory chronic spontaneous urticaria 1
Third-Line Treatment
Cyclosporine is recommended for patients failing both high-dose antihistamines and omalizumab 1, 2
Cyclosporine at 4 mg/kg/day for up to 2 months is effective in approximately two-thirds of patients with severe autoimmune urticaria unresponsive to antihistamines 1, 4
Clinical Pitfalls to Avoid
Do not perform extensive laboratory workups unless history or physical examination suggests specific underlying conditions, as chronic urticaria is idiopathic in 80-90% of cases 3
Do not escalate methylprednisolone above 2 mg/kg/day, as there is no benefit to higher doses 5
Do not rely on topical treatments as primary therapy for urticaria, as the migratory and transient nature of wheals makes this approach ineffective 2
Rule out anaphylaxis in acute presentations, as urticaria can be a feature of anaphylactic reactions requiring immediate epinephrine 5, 4