Recommended Corticosteroid for Acute Urticaria
Prednisolone 50 mg daily for 3 days is the guideline-recommended corticosteroid regimen for acute urticaria in adults. 1, 2, 3
When to Use Corticosteroids in Acute Urticaria
Corticosteroids should only be added when antihistamines alone fail to control severe acute urticaria — they are not first-line therapy. 1, 2, 3
Treatment Algorithm:
Step 1: Start with antihistamines
- Begin with second-generation H1 antihistamines (cetirizine, loratadine, fexofenadine, levocetirizine) at standard doses. 2, 3
- More than 40% of patients respond to antihistamines alone. 2
Step 2: Escalate antihistamine dose if needed
- If inadequate response after 2-4 weeks, increase antihistamine dose up to 4 times the standard dose before adding corticosteroids. 2, 3
Step 3: Add prednisolone only for severe acute cases
- Prednisolone 50 mg orally daily for 3 days for severe acute urticaria not responding to antihistamines. 1, 2, 3
- Lower doses are frequently effective and should be considered to minimize corticosteroid exposure. 1, 2
- Short courses of 3-10 days maximum are appropriate for severe acute exacerbations. 1, 2
Critical Evidence on Corticosteroid Efficacy
The evidence for adding corticosteroids to antihistamines in acute urticaria is weak and contradictory. A 2021 randomized controlled trial found that adding IV dexamethasone to chlorpheniramine did not improve pruritus scores at 60 minutes compared to antihistamine alone, and oral prednisolone for 5 days was associated with more persistent urticaria activity at follow-up. 4 A 2024 systematic review concluded that the addition of corticosteroids to antihistamines in acute urticaria remains unclear and needs further investigation. 5
Despite limited evidence, guidelines still recommend short-course prednisolone for severe acute urticaria based on clinical experience and the need for rapid symptom control in severe cases. 1, 2, 3
Alternative Corticosteroid Formulations
Liquid prednisolone (100 mg) may be used when dysphagia is present, particularly in severe angioedema where swallowing tablets is difficult. 6 This achieves symptom remission comparable to IV administration within 30 minutes. 6
Hydrocortisone is NOT recommended as routine treatment for urticaria — prednisolone is preferred. 3 Hydrocortisone 200 mg IV may be reserved only for urticaria occurring during infusion reactions (e.g., IV iron). 3
Critical Contraindication: Chronic Urticaria
Long-term oral corticosteroids should NEVER be used in chronic urticaria except in very selected cases under regular specialist supervision (Strength of recommendation A). 1, 2, 3 This is a firm contraindication due to cumulative toxicity and poor risk-benefit ratio. 1, 3
For antihistamine-refractory chronic urticaria, escalate to:
- Omalizumab 300 mg subcutaneously every 4 weeks (preferred second-line). 7, 2, 3
- Cyclosporine 4 mg/kg daily for up to 2 months (effective in two-thirds of severe autoimmune urticaria cases). 7, 1, 2, 3
Common Pitfalls to Avoid
The most critical error is using chronic corticosteroids for chronic spontaneous urticaria — this leads to cumulative toxicity without sustained benefit. 1, 2, 3
Do not use corticosteroids as first-line treatment when antihistamines are sufficient. 2, 3 Always attempt antihistamine dose escalation first. 2, 3
Never continue corticosteroids beyond 3-10 days due to cumulative toxicity. 1, 2
Avoid using methylprednisolone or dexamethasone as routine choices — prednisolone 50 mg daily for 3 days is the guideline-specified regimen. 1, 2