What is the recommended treatment for acute urticaria in children?

Treatment for Acute Urticaria in Children

Second-generation non-sedating H1 antihistamines are the first-line treatment for acute urticaria in children, with options including cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine. 1, 2, 3

First-Line Treatment: Second-Generation Antihistamines

• Start with a standard dose of a second-generation H1 antihistamine such as cetirizine, loratadine, or fexofenadine at age-appropriate dosing 1, 2, 4
• Offer at least two different non-sedating antihistamines as trial options, since individual responses and tolerance vary significantly between patients 2, 5
• Cetirizine has the shortest time to maximum concentration, making it advantageous when rapid symptom relief is needed for acute presentations 6, 5
• These agents are preferred over first-generation antihistamines because they cause significantly less sedation and psychomotor impairment, which is particularly important in children 7

Dose Escalation for Inadequate Response

• If symptoms persist after 2-4 weeks of standard dosing, increase the antihistamine dose up to 4 times the standard dose 1, 2, 5
• This dose escalation has become common practice when potential benefits outweigh risks, though it exceeds manufacturer's licensed recommendations 1

Role of Corticosteroids in Severe Acute Urticaria

• Oral corticosteroids should be restricted to short courses (3 days in adults, adjust for children) for severe acute urticaria or angioedema affecting the mouth 1, 2
• However, recent evidence questions their added benefit: two out of three randomized controlled trials found that adding prednisone to antihistamines (cetirizine or levocetirizine) did not improve symptoms compared to antihistamine alone 8
• When used, prednisolone 50 mg daily for 3 days in adults (weight-adjusted for children) may shorten duration, though lower doses are often effective 1
• Long-term oral corticosteroids should not be used in chronic urticaria except in very selected cases under specialist supervision 1

Adjunctive Therapies for Resistant Cases

• First-generation antihistamines (such as hydroxyzine or chlorpheniramine) may be added at night for additional symptom control and to help with sleep, though their sedating effects must be considered 1, 2
• H2 antihistamines (ranitidine or cimetidine) can be combined with H1 antihistamines for resistant cases; the combination of diphenhydramine (IV) and ranitidine (IV) or cimetidine (IV) was most efficient for relief in two out of five studies 1, 8
• Leukotriene receptor antagonists (montelukast) can be useful as add-on therapy for resistant cases 1, 9

General Management Measures

• Identify and minimize aggravating factors including overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 6, 2, 5
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 6
• Patient and parent education about the generally favorable prognosis is important: approximately 50% of patients with acute urticaria presenting with wheals alone will be clear by 6 months 1, 5

Emergency Management

• Intramuscular epinephrine is life-saving for anaphylaxis or severe laryngeal angioedema 1
• Dosing is weight-dependent: 150 µg for children between 15-30 kg, 300 µg for those over 30 kg 1
• If no significant relief after the first dose, a further dose should be given 1
• Parenteral hydrocortisone is often given as an adjunct for severe laryngeal edema, though its action is delayed 1

Common Pitfalls to Avoid

• Do not perform extensive laboratory workup for acute urticaria unless elements of the history or physical examination suggest specific underlying conditions (infections, food/drug hypersensitivity) 9, 4
• Avoid using first-generation antihistamines as first-line monotherapy due to sedating properties that impair school performance and daily activities in children 2, 7
• Do not continue corticosteroids beyond short courses (3-10 days) due to cumulative toxicity, as the evidence for their benefit in acute urticaria is questionable 5, 8

Prognosis

• Acute urticaria typically resolves within 3 weeks in most children 7
• Chronic urticaria (persisting >6 weeks) represents only 0.1% of cases, with acute urticaria being far more common in the pediatric population 3
• More than one-half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 9