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

Prednisone Dosing for Hives

For acute urticaria in adults, prescribe prednisolone 50 mg daily for 3 days, though lower doses are often effective. 1, 2

Treatment Algorithm

First-Line: Antihistamines (Not Corticosteroids)

• Start with second-generation H1 antihistamines at standard doses for 2-4 weeks, as more than 40% of patients respond to antihistamines alone 2
• Never use corticosteroids as first-line treatment when antihistamines are sufficient 2

Second-Line: Updose Antihistamines Before Adding Steroids

• If inadequate response after 2-4 weeks, increase the antihistamine dose up to 4 times the standard dose, as approximately 75% of patients respond to dose escalation 2
• Only consider corticosteroids after antihistamine optimization fails 1, 2

Third-Line: Short-Course Corticosteroids for Acute Urticaria

Standard Dosing:

• Prednisolone 50 mg daily for 3 days in adults is the guideline-recommended regimen 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) 2
• Most patients respond to doses equivalent to 40 mg of prednisone daily 3

Duration:

• Short courses of 3-10 days maximum are appropriate for severe acute exacerbations 2
• Never continue corticosteroids beyond 3-10 days due to cumulative toxicity 2
• The minimum treatment duration should be 2-3 weeks with gradual taper if used for extensive disease 2

Critical Pitfalls to Avoid

For Chronic Urticaria:

• Long-term oral corticosteroids should NOT be used in chronic urticaria (Strength of recommendation A) except in very selected cases under regular specialist supervision 1, 2
• Short tapering courses over 3-4 weeks may be necessary only for urticarial vasculitis and severe delayed pressure urticaria 1

Escalation for Refractory Cases:

• For antihistamine-refractory chronic urticaria, escalate to omalizumab 300 mg subcutaneously every 4 weeks rather than chronic steroids 1, 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

Evidence Quality Considerations

The British Journal of Dermatology guidelines 1 provide the foundational recommendation of prednisolone 50 mg daily for 3 days, noting this is Quality of evidence III. A 2010 retrospective study 4 demonstrated that a short course starting with prednisone 25 mg/day for 3 days induced remission in nearly 50% of antihistamine-resistant chronic urticaria patients, with effects appreciable within 24 hours. However, the higher 50 mg dose remains the standard guideline recommendation to ensure adequate disease control in acute presentations 1, 2.

The key clinical principle: corticosteroids are reserved for acute urticaria not controlled by antihistamines, used for the shortest duration possible (3 days preferred), and never used chronically for chronic spontaneous urticaria. 1, 2