What is the treatment for chronic urticaria in a child?

Treatment of Chronic Urticaria in Children

Start with a standard dose of a second-generation non-sedating H1 antihistamine (cetirizine, loratadine, fexofenadine, desloratadine, or levocetirizine) at age-appropriate dosing, and if symptoms persist after 2-4 weeks, increase the dose up to 4 times the standard dose before considering additional therapies. 1, 2

Stepwise Treatment Algorithm

Step 1: Initial Therapy with Second-Generation Antihistamines

• Begin with a standard dose of a second-generation H1 antihistamine such as cetirizine, loratadine, fexofenadine, desloratadine, or levocetirizine at age-appropriate dosing 1, 2
• These medications are the cornerstone of management and should be taken daily, not as needed 3
• Trial at least two different non-sedating antihistamines, as individual responses and tolerance vary between children 4
• Continue for 2-4 weeks to assess response 1, 5

Step 2: Dose Escalation for Inadequate Control

• If symptoms are not controlled after 2-4 weeks (or earlier if symptoms are intolerable), increase the antihistamine dose up to 4 times the standard dose 1, 2
• This approach exceeds manufacturer's licensed recommendations but is supported when potential benefits outweigh risks 1, 4
• Approximately 50% of pediatric patients require step 2 or higher dosing to achieve control, with younger children (2-6 years) more likely to need dose escalation 6
• Continue high-dose antihistamine therapy and reassess response 1

Step 3: Add Omalizumab for Refractory Cases

• For children with inadequate control on high-dose antihistamines, add omalizumab (anti-IgE monoclonal antibody) at 300 mg every 4 weeks 1, 4
• Allow up to 6 months for response before considering this treatment a failure 1, 4
• Omalizumab is the recommended second-line therapy for chronic spontaneous urticaria unresponsive to antihistamines 4

Step 4: Consider Cyclosporine as Third-Line Therapy

• If omalizumab fails after 6 months, add cyclosporine at up to 5 mg/kg body weight daily 1
• Cyclosporine is effective in approximately 65-70% of patients with severe antihistamine-resistant urticaria 4
• Monitor blood pressure and renal function (blood urea nitrogen and creatinine) every 6 weeks while on cyclosporine 1, 5

Adjunctive Therapies

First-Generation Antihistamines

• First-generation antihistamines (hydroxyzine, chlorpheniramine) may be added at night for additional symptom control and to help with sleep in resistant cases 1, 2
• Avoid using first-generation antihistamines as first-line monotherapy due to sedating properties that impair school performance and daily activities 2

Leukotriene Receptor Antagonists

• Consider adding montelukast as adjunctive therapy, particularly for aspirin-sensitive or autoimmune urticaria 5

H2 Antihistamines

• Adding H2 antihistamines (ranitidine, famotidine) may be helpful for resistant cases 5

Role of Corticosteroids

• Restrict oral corticosteroids to short courses (3-10 days) for severe acute exacerbations or angioedema affecting the mouth 1, 2, 5
• Do not continue corticosteroids beyond short courses due to cumulative toxicity and questionable long-term benefit 2
• Avoid long-term oral corticosteroids in chronic urticaria except in very selected cases under specialist supervision 5

Stepping Down Treatment

• Use an "as much as needed and as little as possible" approach by stepping up and stepping down treatment based on disease control 1
• Do not step down higher-than-standard antihistamine doses before completing at least 3 consecutive months of complete control 1
• Reduce the daily dose by no more than 1 tablet per month during step-down 1
• If control is lost during step-down, return to the last dose that provided complete control 1

General Management Measures

• Identify and minimize aggravating factors including overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 2, 5, 4
• Provide patient and parent education about prognosis: approximately 50% of patients with chronic urticaria will be clear by 6 months, though those with angioedema have a poorer outlook 2, 4
• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 5

Common Pitfalls to Avoid

• Overuse of sedating antihistamines: First-generation antihistamines are overutilized in real-world practice despite guideline recommendations to prioritize non-sedating options 3
• Overuse of oral steroids: Corticosteroids are frequently overutilized when they should be restricted to short courses only 3
• "As needed" dosing: Medications should be taken daily, not as needed, for optimal control 3
• Inadequate dose escalation: Many providers fail to increase antihistamine doses to 4 times the standard dose before adding additional therapies 3
• Premature step-down: Stepping down therapy too quickly before achieving 3 months of complete control increases risk of symptom recurrence 1

Emergency Management

• Administer intramuscular epinephrine (150 µg for children 15-30 kg, 300 µg for those over 30 kg) for anaphylaxis or severe laryngeal angioedema 2

Special Considerations in Children

• Treatment options for pediatric chronic urticaria are primarily based on adult data extrapolated for children 7
• Children with previously resolved chronic urticaria are more likely to require higher antihistamine doses (step 2 or above) to achieve control 6
• Approximately one-third of pediatric patients with chronic spontaneous urticaria have a family history of acute urticaria 6
• The impact on quality of life is more prevalent in older children and adolescents and can be comparable to diabetes and epilepsy 3