Interim Treatment for Urticaria
Start a second-generation non-sedating H1 antihistamine immediately at standard dosing—this is the definitive first-line treatment for urticaria and should not be delayed while awaiting further evaluation. 1, 2
Immediate First-Line Treatment
Begin with one of these second-generation antihistamines at standard doses:
- Cetirizine 10 mg once daily is particularly advantageous because it reaches maximum concentration fastest, providing more rapid symptom relief 1
- Alternatively: desloratadine, fexofenadine, levocetirizine, loratadine, or mizolastine 1, 2
- These medications are safe, effective, and appropriate to start immediately without waiting for specialist evaluation 1, 2
Offer the patient at least two different antihistamines to trial, as individual responses and tolerance vary significantly between patients 1, 2. If one doesn't work well after a few days, switch to another.
Adjunctive Symptomatic Measures
While the antihistamine takes effect, recommend:
- Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic itch relief 3
- Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1, 2, 3
If Inadequate Response After 2-4 Weeks
Increase the antihistamine dose up to 4 times the standard dose before considering other therapies 1, 2. For example, cetirizine can be increased from 10 mg to 40 mg daily 1.
This dose escalation is evidence-based and recommended by guidelines—cetirizine at 10 mg was effective for complete suppression of urticaria in both short-term and intermediate-term treatment 4, and doubling the dose has proven efficacy in patients with inadequate response 5.
Critical Pitfall to Avoid
Do not use oral corticosteroids for routine urticaria management 1, 2. Corticosteroids should be restricted to short courses only for severe acute urticaria or angioedema affecting the mouth 6, 2. They have slow onset of action, work by inhibiting gene expression rather than providing acute relief, and chronic use leads to cumulative toxicity that outweighs any benefit 1.
Special Considerations
If the patient has angioedema (swelling of deeper tissues):
- The same antihistamine approach applies 2
- If angioedema occurs without wheals, avoid ACE inhibitors 2, 3
- Ensure the patient understands that angioedema typically resolves slower than wheals, taking up to 72 hours or longer 7
Pregnancy considerations:
- Avoid antihistamines if possible, especially during the first trimester 1, 2
- If necessary, choose chlorphenamine due to its long safety record 1, 2
Renal impairment:
Prognosis to Share with Patient
Approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 1, 2. This reassurance can help with treatment adherence while awaiting further evaluation.