What is the recommended dose of prednisone (corticosteroid) for outpatient treatment of hives (urticaria)?

Prednisone for Outpatient Treatment of Hives (Urticaria)

For acute urticaria in adults, prescribe prednisolone 50 mg daily for 3 days as the guideline-recommended regimen, reserving corticosteroids only for cases not adequately controlled with antihistamines. 1, 2

Treatment Algorithm for Acute Urticaria

First-Line Therapy

• Start with second-generation H1 antihistamines (cetirizine, loratadine, desloratadine, fexofenadine, or levocetirizine) at standard doses for 2-4 weeks 2
• More than 40% of patients respond to antihistamines alone 2

Second-Line Therapy

• If inadequate response after 2-4 weeks, increase the antihistamine dose up to 4 times the standard dose before considering corticosteroids 1, 2
• Approximately 75% of patients respond to antihistamine dose escalation 2

Corticosteroid Therapy (Third-Line)

• Add prednisolone 50 mg daily for 3 days if severe acute urticaria persists despite antihistamines 1, 2
• Lower doses are frequently effective and should be considered to minimize corticosteroid exposure 1, 2
• Alternative dosing: prednisone 0.5-1 mg/kg/day until hives resolve (maximum 60 mg/day) 1
• Short courses of 3-10 days maximum are appropriate for severe acute exacerbations 1, 2

Evidence Supporting Corticosteroid Use

Efficacy Data

• A 4-day prednisone burst (20 mg every 12 hours) added to antihistamines significantly reduced itch scores at 2 and 5 days compared to antihistamines alone (P < 0.0001) 3
• A single short course of prednisone (starting at 25 mg/day for 3 days) induced remission in nearly 50% of antihistamine-resistant chronic urticaria patients 4
• For patients with low to moderate probability (17.5%-64%) of improving with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by 14-15% absolute difference (NNT = 7) 5
• However, for patients with high probability (95.8%) of improving with antihistamines alone, corticosteroids provide only 2.2% absolute benefit (NNT = 45) 5

Safety Considerations

• Systemic corticosteroids likely increase adverse events by 15% (number needed to harm = 9) 5
• No serious adverse effects were noted in short-term studies 3, 6

Critical Contraindications

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, 2

• This is a firm contraindication due to cumulative toxicity and poor risk-benefit ratio 1, 2
• The most critical error is using chronic corticosteroids for chronic spontaneous urticaria 1

Alternative Therapies for Refractory Chronic Urticaria

• Escalate to omalizumab 300 mg subcutaneously every 4 weeks for antihistamine-refractory chronic urticaria 2
• Cyclosporine 4 mg/kg daily for up to 2 months is effective in two-thirds of severe autoimmune urticaria cases unresponsive to antihistamines 1, 2

Practical Dosing Guidance

Administration Timing

• Administer prednisone in the morning prior to 9 am to minimize adrenal suppression 7
• Take before, during, or immediately after meals to reduce gastric irritation 7

Dose Range

• Initial dosage may vary from 5 mg to 60 mg per day depending on disease severity 7
• For acute urticaria: 40-80 mg/day in 1 or 2 divided doses until symptoms resolve 8
• Most patients respond to doses equivalent to 40 mg of prednisone daily 9

Duration and Tapering

• For courses less than 1 week, no taper is necessary 8
• For courses up to 10 days, tapering is probably unnecessary, especially if patients are concurrently taking inhaled corticosteroids 8
• If long-term therapy is required, withdraw gradually rather than abruptly 7

Common Pitfalls to Avoid

• Never use corticosteroids as first-line treatment when antihistamines are sufficient 2
• Never continue corticosteroids beyond 3-10 days due to cumulative toxicity 1, 2
• Never use chronic corticosteroids for chronic spontaneous urticaria 1, 2
• Avoid aspirin and NSAIDs in patients with urticaria, as they can exacerbate symptoms 2
• Do not use first-generation antihistamines as first-line monotherapy due to sedating properties 2

Emergency Situations

• For anaphylaxis or severe laryngeal angioedema, administer epinephrine 0.5 mL of 1:1000 (500 µg) intramuscularly immediately 2
• High-concentration liquid prednisolone (100 mg or >250 mg) achieves symptom remission of at least 50% in less than 30 minutes, comparable to intravenous therapy 6