First-Line Treatment for Wheals (Urticaria) on the Back
Second-generation H1 antihistamines are the first-line treatment for wheals on the back, with options including cetirizine, loratadine, fexofenadine, desloratadine, or levocetirizine taken once daily. 1, 2
Initial Management Approach
Immediate Treatment Strategy
Start with a second-generation H1 antihistamine at standard dosing (e.g., cetirizine 10mg, loratadine 10mg, fexofenadine 180mg, desloratadine 5mg, or levocetirizine 5mg once daily). 1, 2
Offer the patient a choice of at least two different second-generation antihistamines, as individual responses and tolerance vary significantly between patients. 1
If inadequate response after 2-4 weeks at standard dosing, increase the antihistamine dose up to 4 times the standard daily dose before considering the treatment a failure. 3, 4 This off-label dose escalation is common practice when potential benefits outweigh risks. 1
Adjunctive Measures
Apply cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream for symptomatic relief of itching. 1
Advise avoidance of nonspecific aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine, as these can worsen urticaria. 1, 4
When Standard Treatment Fails
Second-Line Options
Add a sedating antihistamine at bedtime if pruritus interferes with sleep, though avoid long-term use in elderly patients due to dementia risk. 1
Consider adding an H2 antihistamine (though evidence for benefit is limited) or a leukotriene receptor antagonist for resistant cases. 1, 2
Reserve short courses of oral corticosteroids (typically 5-7 days) only for severe acute flares or disabling symptoms, never for long-term maintenance therapy. 1, 4
Referral for Advanced Therapy
If symptoms persist despite maximized antihistamine therapy for 2-4 weeks, refer for omalizumab (300mg subcutaneously every 4 weeks), which is the next step for refractory chronic urticaria. 4
Allow up to 6 months to assess omalizumab response before considering it a treatment failure. 4
Cyclosporine (up to 5mg/kg body weight) can be considered for severe refractory cases unresponsive to omalizumab, with appropriate monitoring of blood pressure and renal function. 3, 2
Critical Diagnostic Considerations
Rule Out Serious Conditions
If wheals last longer than 24 hours, consider urticarial vasculitis and obtain a lesional skin biopsy to look for leucocytoclasia, endothelial damage, and perivascular fibrin deposition. 1, 3
If angioedema develops (especially without wheals), immediately check serum C4 level to rule out hereditary angioedema, which requires completely different management. 1, 4
Avoid ACE inhibitors in patients with angioedema without wheals, and use with extreme caution if angioedema accompanies urticaria. 1, 4
Assessment Tools
Use the 7-Day Urticaria Activity Score (UAS7) to objectively track disease activity, scoring both wheal count (0-3) and pruritus intensity (0-3) daily for one week. 1
Apply the Urticaria Control Test (UCT) to assess overall disease control, with a score ≥12 indicating well-controlled disease. 3, 4
Common Pitfalls to Avoid
Never use prolonged corticosteroids as maintenance therapy for chronic urticaria—this exposes patients to significant morbidity (osteoporosis, diabetes, hypertension, weight gain) without addressing the underlying disease mechanism. 1, 4
Do not perform extensive laboratory workups unless the history or physical examination suggests specific underlying conditions—chronic urticaria is idiopathic in 80-90% of cases. 2, 5
Recognize that first-generation antihistamines as monotherapy are now less preferred due to sedation, reduced concentration, and impaired performance, though they remain useful as adjunctive nighttime therapy. 1
Continue effective treatment for at least 3-6 months after achieving complete symptom control before attempting dose reduction to prevent relapse. 3, 4