What is the management for urticaria?

Management of Urticaria

Start with second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, or mizolastine) at standard doses, and if symptoms remain inadequately controlled after 2-4 weeks, increase the dose up to 4 times the standard dose before considering additional therapies. 1, 2

First-Line Treatment: Antihistamines

• Second-generation H1 antihistamines are the mainstay of therapy for both acute and chronic urticaria 3, 2, 4
• Prescribe antihistamines on a regular daily basis, not just after hives appear 5
• Offer at least two different non-sedating antihistamines to each patient, as individual responses and tolerance vary significantly between agents 1, 2
• First-generation antihistamines (like hydroxyzine) may be added at night for additional symptom control and to help with sleep, but avoid as first-line monotherapy due to sedating properties 2

Dose Escalation Strategy

• If inadequate control after 2-4 weeks at standard dosing, increase to up to 4 times the standard dose when potential benefits outweigh risks 1, 2
• This updosing approach should be attempted before moving to second-line therapies 1

Second-Line Treatment: Omalizumab

• For chronic spontaneous urticaria unresponsive to high-dose antihistamines, add omalizumab 300 mg subcutaneously every 4 weeks 1, 2, 6
• Allow up to 6 months for patients to respond to omalizumab before considering it a treatment failure 1, 2
• If insufficient response at standard dosing, increase to 600 mg every 2 weeks as the maximum recommended dose 1
• Omalizumab demonstrated significant efficacy in clinical trials, with 36% of patients achieving complete symptom resolution (no itch, no hives) at 12 weeks compared to 9% with placebo 6

Third-Line Treatment: Cyclosporine

• For patients who do not respond to high-dose antihistamines and omalizumab within 6 months, add cyclosporine at a dose of 4-5 mg/kg body weight daily 1, 2, 7
• Cyclosporine is effective in approximately 65-70% of patients with severe urticaria 1
• Monitor blood pressure and renal function every 6 weeks due to potential nephrotoxicity and hypertension 1, 2
• A treatment duration of 16 weeks is superior to 8 weeks for reducing therapeutic failures 1

Role of Corticosteroids

• Restrict oral corticosteroids to short courses (3-10 days) for severe acute exacerbations or acute urticaria with angioedema affecting the mouth only 1, 2
• Recent evidence shows that adding corticosteroids to antihistamines for acute urticaria did not improve symptoms compared to antihistamines alone in 2 out of 3 randomized trials 8
• Long-term oral corticosteroids should not be used in chronic urticaria except in very selected cases under regular specialist supervision 1, 2
• For urticarial vasculitis specifically, short tapering courses over 3-4 weeks may be necessary 7

Identify and Minimize Aggravating Factors

• Avoid overheating, stress, alcohol, hot water, and tight clothing 2, 9
• Discontinue aspirin, NSAIDs, and codeine in patients with urticaria, as these can worsen symptoms 2, 7
• Avoid ACE inhibitors in patients with angioedema without wheals 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 2

Special Considerations by Urticaria Type

Physical Urticarias

• Managed similarly with antihistamines as first-line, but identify and minimize the specific physical trigger (pressure, cold, heat, vibration, etc.) 3

Urticarial Vasculitis

• Distinguished by lesions lasting >24 hours (versus 2-24 hours in ordinary urticaria) 7
• Requires lesional skin biopsy to confirm small-vessel vasculitis 7
• May require more prolonged corticosteroid treatment and earlier consideration of immunomodulatory agents 7

Cholinergic Urticaria

• Presents with punctate (1-3 mm diameter) intensely pruritic wheals with erythematous flaring after core body temperature increase 1
• Do not confuse with exercise-induced anaphylaxis, which requires emergency epinephrine and is not responsive to prophylactic antihistamines 1

Special Populations

Renal Impairment

• Avoid acrivastine in moderate renal impairment 2
• Halve the dose of cetirizine, levocetirizine, and hydroxyzine 2

Hepatic Impairment

• Avoid mizolastine in significant hepatic impairment 2

Pregnancy

• Avoid antihistamines if possible, especially during the first trimester 2
• Choose chlorphenamine if necessary due to its long safety record 2

Emergency Management

• For severe urticaria with anaphylaxis or angioedema affecting the airway, administer intramuscular epinephrine 0.5 mL of 1:1000 (500 µg) immediately 2
• Prescribe fixed-dose epinephrine pens (300 µg for adults) for patients at risk of life-threatening attacks 2

Prognosis

• About 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 2
• Patients with wheals and angioedema have a poorer outlook, with over 50% still having active disease after 5 years 2