What is the treatment for urticaria?

Treatment of Urticaria

Second-generation H1-antihistamines at standard doses are the first-line treatment for urticaria, and should be increased up to 4 times the standard dose if symptoms remain inadequately controlled after 2-4 weeks. 1, 2

Initial Management Approach

First-Line Therapy

• Start with non-sedating second-generation H1-antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine) at standard manufacturer-recommended doses 2, 3
• Offer patients at least two different non-sedating antihistamines as individual responses vary significantly between agents 1, 2
• These agents are preferred over first-generation antihistamines due to superior safety profiles and reduced sedation 2

Dose Escalation Strategy

• If inadequate symptom control persists after 2-4 weeks, increase the dose of second-generation H1-antihistamines up to 4 times the standard dose 1, 2, 3
• This practice of exceeding manufacturer's licensed recommendations has become common when potential benefits outweigh risks 4
• Over 40% of patients with urticaria demonstrate good response to antihistamines alone 4, 5

Step-Up Treatment for Resistant Cases

Adjunctive Therapies

• Add H2-antihistamines or leukotriene receptor antagonists (such as montelukast) for cases resistant to high-dose H1-antihistamines 1, 2, 3
• Consider adding sedating antihistamines at night for additional symptom control 4
• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 1, 2

Corticosteroid Use

• Restrict oral corticosteroids to short courses (3-4 weeks) for severe acute urticaria or life-threatening angioedema affecting the mouth 4, 5
• Avoid long-term oral corticosteroids except in very selected cases under regular specialist supervision 1
• Short tapering courses may be necessary for specific conditions like delayed pressure urticaria or urticarial vasculitis 4, 1

Advanced Therapies for Refractory Disease

Specialist Referral Indications

• For inadequate response to high-dose antihistamines and short corticosteroid courses, add omalizumab 300mg subcutaneously every 4 weeks 1
• Allow up to 6 months for patients to respond to omalizumab therapy 1
• If insufficient response to standard omalizumab dosing, consider updosing by shortening intervals and/or increasing dosage (maximum 600mg every 14 days) 1
• Cyclosporine (up to 5mg/kg body weight) can be added for patients unresponsive to higher-than-standard omalizumab doses, with mandatory monitoring of blood pressure and renal function every 6 weeks 1, 2

Critical Avoidance Measures

Drug and Trigger Avoidance

• Avoid aspirin and NSAIDs in all urticaria patients, as they inhibit cyclooxygenase and can significantly exacerbate symptoms 5
• Discontinue ACE inhibitors in patients with angioedema without wheals, and use cautiously when angioedema accompanies urticaria 5
• Avoid codeine and other drugs that cause non-immunological mast cell degranulation 4, 2
• Minimize non-specific aggravating factors including overheating, stress, and alcohol 1, 2

Special Considerations by Urticaria Type

Physical Urticaria

• Weals typically resolve within 1 hour (except delayed pressure urticaria, which can last up to 48 hours) 4, 2
• Focus on avoiding specific physical triggers while maintaining standard antihistamine therapy 2
• In cholinergic urticaria, emphasize avoiding core temperature increases 2

Urticarial Vasculitis

• Lesions persist longer than 24 hours, distinguishing it from ordinary urticaria (2-24 hours) 4, 1
• Confirm diagnosis with lesional skin biopsy showing leucocytoclasia, endothelial damage, perivascular fibrin deposition, and red cell extravasation 1
• More prolonged corticosteroid treatment may be necessary compared to ordinary urticaria 4, 1

Anaphylaxis with Urticaria

• Administer intramuscular epinephrine immediately for life-threatening reactions involving urticaria with angioedema, airway swelling, bronchospasm, or hypotension 6, 7
• Epinephrine alleviates pruritus, urticaria, and angioedema through its effects on alpha and beta-adrenergic receptors 6
• Follow with antihistamines and corticosteroids as adjunctive therapy 8, 7

Monitoring and Treatment Adjustment

Follow-Up Protocol

• Regularly assess disease activity, quality of life impact, and treatment response using validated patient-reported outcome measures 1, 2
• After achieving complete symptom control for at least 3 consecutive months, consider stepping down therapy 1, 2
• Reduce daily dose gradually, no more than 1 tablet per month during step-down 2
• If symptoms recur during dose reduction, return to the last effective dose that provided complete control 2

Prognosis

• More than 50% of patients with chronic urticaria (weals and angioedema) may have active disease after 5 years, indicating a poorer outlook compared to those with weals alone 4
• Over one-half of patients with chronic urticaria will experience resolution or improvement within one year 3, 9