What is the recommended treatment for itching and hives (urticaria) in early pregnancy?

Treatment of Itching and Hives in Early Pregnancy

For itching and hives in early pregnancy, start with cetirizine or loratadine as first-line treatment, as these second-generation antihistamines are FDA Pregnancy Category B drugs with the best safety profile and should be used at standard doses initially. 1

First-Line Treatment Approach

• Cetirizine 10 mg daily or loratadine 10 mg daily are the preferred antihistamines because they have the most robust safety data during pregnancy and are classified as FDA Pregnancy Category B (animal studies show no fetal harm, though controlled human studies in pregnant women are lacking). 1, 2

• Both FDA drug labels advise asking a health professional before use during pregnancy, but clinical guidelines support their use when treatment is necessary. 3, 4

• Avoid all antihistamines during the first trimester if possible, though none has been proven teratogenic in humans; however, when treatment is medically necessary, cetirizine and loratadine remain the safest options. 1

• Never use hydroxyzine in early pregnancy—it is specifically contraindicated during this period despite being commonly used for urticaria outside of pregnancy. 1, 5, 2

Dose Escalation Strategy

• Start with standard doses (cetirizine 10 mg daily or loratadine 10 mg daily). 1

• If symptom control is inadequate after 2-4 weeks, increase the dose up to 4 times the standard dose (e.g., cetirizine 40 mg daily or loratadine 40 mg daily), weighing potential benefits against risks. 1, 2

• Recent real-world data from 288 pregnant women with chronic urticaria showed that 35.1% used standard-dose second-generation antihistamines during pregnancy with no increased risk of medical problems at birth compared to population norms. 6

Alternative First-Generation Antihistamine

• Chlorphenamine may be selected if second-generation antihistamines fail, as UK clinicians favor it due to its long safety record during pregnancy, despite being sedating. 1, 2

• First-generation antihistamines other than chlorphenamine should generally be avoided due to sedating effects and cognitive impairment risks. 5

Adjunctive Non-Pharmacologic Measures

• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief without systemic absorption. 1

• Use emollients to prevent skin dryness, avoid hot baths or showers, and keep nails shortened to minimize scratching. 7, 8

• Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine. 1, 2

Second-Line Treatment for Refractory Cases

• Omalizumab 300 mg subcutaneously every 4 weeks is recommended for severe urticaria unresponsive to high-dose antihistamines, though data in pregnancy are limited. 1, 2

• Allow up to 6 months to evaluate response before considering alternatives. 1, 2

• Real-world data showed 5.6% of pregnant women with chronic urticaria used omalizumab during pregnancy without increased adverse outcomes. 6

Corticosteroids: Use Only for Severe Acute Exacerbations

• Limit oral corticosteroids to short 3-day courses only for severe acute exacerbations that cannot be managed with antihistamines. 1

• Prednisolone is preferred over other corticosteroids because it is 90% inactivated by the placenta, minimizing fetal exposure, whereas betamethasone and dexamethasone cross the placenta more readily. 7

• Short tapering courses over 3-4 weeks may be necessary for severe cases, but long-term use should be avoided due to risks of intrauterine growth retardation. 7, 1

Emergency Management

• Intramuscular epinephrine 0.5 mL of 1:1000 (500 µg) remains life-saving for anaphylaxis or severe laryngeal angioedema even during pregnancy. 1, 2

• Fixed-dose epinephrine auto-injectors (300 µg) should be prescribed for patients at risk of life-threatening attacks. 1, 2

Critical Safety Considerations

• The preterm birth rate in treated pregnant women with urticaria (11.6%) was similar to untreated women (8.7%), suggesting that appropriate treatment does not increase preterm birth risk. 6

• Emergency referrals for urticaria and twin births were identified as risk factors for preterm birth, emphasizing the importance of maintaining disease control during pregnancy. 6

• More than 90% of newborns from mothers with chronic urticaria were healthy at birth, with no link between treatments used and medical problems. 6

Common Pitfalls to Avoid

• Do not withhold necessary antihistamine treatment out of excessive caution, as uncontrolled urticaria requiring emergency care poses greater risks than appropriate use of cetirizine or loratadine. 6

• Do not use diphenhydramine as first-line, as it has been associated with cleft palate development despite being frequently used during pregnancy. 7

• Avoid oral decongestants during the first trimester due to conflicting reports of associations with gastroschisis and small intestinal atresia. 7