What is the role of steroids, such as prednisone, in the treatment of hives (urticaria)?

Steroids for Hives: Role and Recommendations

Oral corticosteroids should be reserved for short courses (3-10 days) in severe acute urticaria or chronic urticaria flares that fail to respond adequately to antihistamines, using prednisolone 50 mg daily for 3 days or prednisone 0.5-1 mg/kg/day, but should never be used for long-term maintenance therapy in chronic urticaria. 1, 2, 3

First-Line Treatment: Antihistamines, Not Steroids

• Non-sedating second-generation H1 antihistamines (cetirizine 10 mg daily, loratadine 10 mg daily, fexofenadine, desloratadine, or levocetirizine) are the mainstay of urticaria treatment. 1, 2, 4
• Over 40% of patients respond to standard-dose antihistamines alone, and approximately 75% respond when doses are escalated. 4
• If inadequate response after 2-4 weeks at standard doses, increase antihistamines up to 4 times the standard dose before considering corticosteroids. 1, 2, 4

When to Use Corticosteroids: Severity-Based Algorithm

Mild Urticaria (<10% Body Surface Area)

• Continue standard-dose oral antihistamines. 2
• Add topical corticosteroids if needed: Class I (clobetasol propionate, betamethasone dipropionate) for body; Class V/VI (hydrocortisone 2.5%, desonide) for face. 1, 2
• No systemic corticosteroids indicated. 2

Moderate Urticaria (10-30% Body Surface Area)

• Continue oral antihistamines at standard or increased doses (up to 4x). 2, 4
• Add topical corticosteroids as above. 1, 2
• Systemic corticosteroids generally not needed at this stage. 2

Severe Acute Urticaria (>30% Body Surface Area)

• Prednisone 0.5-1 mg/kg/day (or prednisolone 50 mg daily for 3 days) until hives resolve to grade 1 or less. 2, 3, 4
• Continue oral antihistamines concurrently. 1, 2
• Consider same-day dermatology consultation. 2
• Rule out systemic hypersensitivity with CBC with differential and comprehensive metabolic panel. 1, 2
• Maximum duration: 3-10 days. 3, 4

Evidence for Efficacy

A 2024 meta-analysis of 944 patients found that add-on systemic corticosteroids likely improve urticaria activity, but the benefit depends heavily on antihistamine responsiveness. 5

• For patients with low-to-moderate probability (17.5%-64%) of improving with antihistamines alone, corticosteroids provide a 14-15% absolute improvement (number needed to treat = 7). 5
• For patients with high probability (95.8%) of improving with antihistamines alone, corticosteroids provide only a 2.2% absolute improvement (number needed to treat = 45). 5
• However, corticosteroids also increase adverse events by 15% (number needed to harm = 9). 5

A 2010 retrospective study of 750 patients with antihistamine-resistant chronic urticaria found that a single short course of prednisone 25 mg/day for 3 days induced remission in nearly 50% of patients, with effects appreciable within 24 hours. 6 A second course induced remission in an additional 9%. 6

Critical Contraindication: Chronic Urticaria

Long-term oral corticosteroids should NOT be used in chronic urticaria except in very selected cases under regular specialist supervision (Strength of recommendation A). 1, 3, 4

• This is a firm contraindication due to cumulative toxicity and unfavorable risk-benefit ratio. 3
• A 2008 prospective study of 17 patients with severe chronic urticaria on chronic steroids found that after withdrawal, 47% had short relapses but 35% achieved complete remission at 12 months, suggesting oral steroids may actually interfere with antihistamine efficacy. 7
• For antihistamine-refractory chronic urticaria, escalate to omalizumab 300 mg subcutaneously every 4 weeks or cyclosporine 4 mg/kg daily for up to 2 months instead of chronic corticosteroids. 3, 4

Practical Dosing Considerations

• Lower corticosteroid doses are frequently effective and should be considered to minimize exposure. 3, 4
• Prednisolone is preferred over methylprednisolone for urticaria. 3, 4
• For patients requiring emergency treatment with severe dysphagia, high-concentration liquid prednisolone (100 mg or >250 mg) achieves symptom control comparable to intravenous therapy, with remission of at least 50% of symptoms in less than 30 minutes. 8

Common Pitfalls to Avoid

• Never use corticosteroids as first-line treatment when antihistamines are sufficient. 4
• Never continue corticosteroids beyond 3-10 days due to cumulative toxicity. 3, 4
• Never use chronic corticosteroids for chronic spontaneous urticaria—this is the most critical error. 3, 4
• Do not use first-generation antihistamines as first-line monotherapy due to sedating properties. 4
• Avoid aspirin and NSAIDs in patients with urticaria, as they can exacerbate symptoms. 4

Adjunctive Measures When Using Corticosteroids

• Start proton pump inhibitor for GI prophylaxis when using systemic corticosteroids. 1, 2
• Add PCP prophylaxis if treatment exceeds 3 weeks at >30 mg prednisone equivalent/day. 1, 2
• Consider cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief. 2

Special Populations

• Avoid corticosteroids if possible, especially in first trimester of pregnancy. 3
• If necessary, use lowest effective dose for shortest duration. 3
• Assess for airway compromise in cases with angioedema; consider epinephrine 0.5 mL of 1:1000 (500 µg) intramuscularly for severe laryngeal angioedema or anaphylaxis. 4