Prednisone Dosing for Urticaria
For acute urticaria, prescribe prednisolone 50 mg daily for 3 days, reserving corticosteroids only for cases not adequately controlled with antihistamines. 1, 2, 3
Treatment Algorithm
First-Line: Antihistamines (Always Start Here)
- Begin with second-generation H1 antihistamines (cetirizine, loratadine, desloratadine, fexofenadine, levocetirizine) at standard doses for 2-4 weeks 2, 3
- More than 40% of patients respond to antihistamines alone 2, 3
Second-Line: Updose Antihistamines Before Steroids
- If inadequate response after 2-4 weeks, increase antihistamine dose up to 4 times the standard dose 4, 2, 3
- Approximately 75% of patients respond to antihistamine dose escalation 2, 3
- Do not proceed to corticosteroids until this step has been attempted 3
Third-Line: Short-Course Corticosteroids (Acute Urticaria Only)
When antihistamines fail to control severe acute urticaria:
- Prednisolone 50 mg daily for 3 days (guideline-recommended regimen) 1, 2, 3
- Alternative dosing: Prednisone 0.5-1 mg/kg/day (maximum 60 mg/day) until hives resolve 1, 3
- Lower doses are frequently effective and should be considered to minimize exposure 1, 2, 3
- Maximum duration: 3-10 days for severe acute exacerbations 1, 2, 3, 5
The evidence strongly supports the 50 mg daily for 3 days regimen from the British Journal of Dermatology and American Academy of Allergy, Asthma, and Immunology guidelines 1, 2, 3. While older literature mentions 40 mg daily 6, the more recent and authoritative guidelines consistently recommend 50 mg for 3 days.
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, 2, 3, 5
- This is a firm contraindication due to cumulative toxicity and poor risk-benefit ratio 1, 5
- Chronic corticosteroids are never appropriate for chronic spontaneous urticaria 1, 2, 3, 5
For Antihistamine-Refractory Chronic Urticaria:
- Omalizumab 300 mg subcutaneously every 4 weeks (effective in 70% of patients) 4, 3, 5
- Cyclosporine 4 mg/kg daily for up to 2 months if omalizumab fails (effective in 65-70% of patients) 4, 1, 3, 5
- Monitor blood pressure and renal function (BUN, creatinine) every 6 weeks with cyclosporine 4, 5
Common Pitfalls to Avoid
- Never use corticosteroids as first-line treatment when antihistamines are sufficient 3
- Never continue corticosteroids beyond 3-10 days due to cumulative toxicity 1, 2, 3, 5
- Never use chronic corticosteroids for chronic spontaneous urticaria - this is the most critical error 1, 2, 3, 5
- Avoid aspirin and NSAIDs as they can exacerbate urticaria 2, 3
- Do not use first-generation antihistamines as first-line monotherapy due to sedating properties 2, 3