What is the treatment for urticaria (hives) in the postpartum period?

Treatment of Urticaria in the Postpartum Period

For postpartum urticaria, use second-generation antihistamines (cetirizine or loratadine) as first-line therapy, as these are safe during breastfeeding and have the best evidence for efficacy and safety. 1

First-Line Treatment: Second-Generation Antihistamines

• Start with cetirizine 10 mg daily or loratadine 10 mg daily as these are the preferred agents with FDA Pregnancy Category B classification and excellent safety profiles that extend into the postpartum/breastfeeding period 1
• Cetirizine has the shortest time to maximum concentration, making it advantageous when rapid symptom relief is needed 2
• If one antihistamine is ineffective or poorly tolerated, switch to an alternative second-generation agent (fexofenadine 180 mg, desloratadine 5 mg, or levocetirizine 5 mg) as individual responses vary significantly 2, 3

Dose Escalation Strategy

• If standard dosing provides inadequate control after 2-4 weeks, increase the antihistamine dose up to 4 times the standard dose (e.g., cetirizine 40 mg daily or loratadine 40 mg daily) 1, 2, 3
• This dose escalation is well-supported by guidelines and should be attempted before adding other medications 1

Adjunctive Nighttime Treatment

• For persistent nighttime symptoms despite optimized second-generation antihistamines, consider adding a first-generation antihistamine at bedtime (such as chlorphenamine) to improve sleep 3
• Avoid hydroxyzine in the early postpartum period if still breastfeeding, as it is contraindicated in early pregnancy and caution extends to lactation 1, 3

Second-Line Treatment: Omalizumab

• For urticaria unresponsive to high-dose antihistamines (up to 4x standard dose), add omalizumab 300 mg subcutaneously every 4 weeks 1, 2, 3
• Allow up to 6 months to evaluate response before considering this treatment a failure, as approximately 70% of antihistamine-refractory patients respond 1, 4

Third-Line Treatment: Cyclosporine

• For patients failing both high-dose antihistamines and omalizumab, cyclosporine 4-5 mg/kg daily for up to 2 months is effective in 65-70% of severe cases 2, 3, 4
• Monitor blood pressure and renal function regularly due to potential nephrotoxicity and hypertension risk 2, 3

Corticosteroids: Use Sparingly and Briefly

• Limit oral corticosteroids to short 3-day courses for severe acute exacerbations only 1, 3
• Prednisolone is preferred over other corticosteroids as it is 90% inactivated by the placenta (relevant if still in early postpartum period) 1
• Avoid chronic corticosteroid use due to cumulative dose- and time-dependent toxicity 4

Non-Pharmacologic Adjunctive Measures

• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief without systemic absorption 1, 2
• Use emollients regularly to prevent skin dryness, avoid hot baths/showers, and keep nails short to minimize scratching damage 1, 2
• Identify and eliminate aggravating factors: overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1, 2, 3

Critical Safety Considerations

• Keep intramuscular epinephrine 0.5 mL of 1:1000 (500 µg) immediately available for severe urticaria with anaphylaxis or laryngeal angioedema 1, 3
• Prescribe fixed-dose epinephrine auto-injectors (300 µg) for patients at risk of life-threatening attacks 1, 3

Common Pitfalls to Avoid

• Do not use diphenhydramine as first-line therapy due to significant sedation, cognitive impairment, and association with cleft palate development when used during pregnancy 1, 2
• Avoid NSAIDs in aspirin-sensitive patients with urticaria 2, 3
• Do not add H2-antihistamines or leukotriene antagonists, as evidence does not support significant efficacy 2, 4

Special Consideration: Postpartum PUPPP

• While rare, pruritic urticarial papules and plaques of pregnancy (PUPPP) can present postpartum 5, 6
• Treatment follows the same algorithm as above, though these cases may require the brief corticosteroid course mentioned for severe exacerbations 6