What is the first line treatment for urticaria in children?

First-Line Treatment for Urticaria in Children

Second-generation non-sedating H1 antihistamines are the first-line treatment for urticaria in children, with cetirizine, loratadine, desloratadine, fexofenadine, or levocetirizine as preferred options. 1, 2

Initial Treatment Approach

Starting Therapy

• Begin with a second-generation antihistamine at standard dosing 1, 3
• Offer the child's family a choice between at least two different antihistamines, as individual response and tolerance vary significantly between patients 1, 2
• Cetirizine has the shortest time to maximum concentration, making it advantageous when rapid symptom relief is needed 1, 3
• Standard pediatric dosing should be weight-appropriate and follow manufacturer guidelines 4

Why Second-Generation Antihistamines Are Preferred

• First-generation antihistamines (like diphenhydramine) cause significant sedation, drowsiness, and impaired concentration that negatively affects school performance in children 5, 6, 7
• Second-generation agents are safer, cause less sedation, and are more efficacious 6, 7
• The sedating effects of first-generation antihistamines should not substitute for proper management with appropriate topical or systemic therapies 5

Dose Escalation Strategy

When Standard Dosing Fails

• If symptom control is inadequate after 2-4 weeks of standard dosing, increase the antihistamine dose up to 4 times the standard dose before adding other therapies 1, 3, 2
• This up-dosing approach is supported by multiple guidelines and is safe in the pediatric population 1, 8
• Among the up-dosing options, bilastine and levocetirizine may be safely increased to four times the standard dose, while fexofenadine has been studied at three times the conventional dose 8
• Cetirizine up-dosing may increase the risk of dose-related sedation, which is an important consideration in children 8

Evidence for Up-Dosing in Children

• Only cetirizine and rupatadine up-dosing have documented efficacy and safety specifically in the pediatric population 8
• A four-fold dose of cetirizine (40mg daily in adults) was necessary to significantly improve multiple urticaria parameters in one study, though doubling the dose improved only pruritus 5

Role of Corticosteroids

Limited Use in Acute Urticaria

• Oral corticosteroids can shorten the duration of acute urticaria episodes 1
• Restrict corticosteroids to short courses of 3-10 days only for severe acute exacerbations or angioedema involving the mouth 1, 2
• Corticosteroids may be added in severe cases of acute urticaria in infants when antihistamines alone are insufficient 4
• Long-term oral corticosteroids should not be used in chronic urticaria except in highly selected cases under specialist supervision 1

Adjunctive Measures

Trigger Identification and Avoidance

• Identify and minimize aggravating factors including overheating, stress, alcohol (in older children), and certain medications (aspirin, NSAIDs, codeine) 1, 2
• In infants and young children, controlling environmental temperature through rational use of bathing, showering, swimming, and air conditioning can decrease symptoms and reduce the need for antihistamines 1
• Avoid NSAIDs in aspirin-sensitive patients with urticaria 2

Symptomatic Relief

• Cooling lotions (calamine or 1% menthol in aqueous cream) can provide additional symptomatic relief 1

Special Considerations for Pediatric Patients

Age-Specific Features

• Acute urticaria in newborns and infants is typically generalized and characterized by large, annular, or geographic plaques that are often slightly raised 4
• The clinical features depend on the peculiar structure of neonatal and infant skin 4
• Acute urticaria is less common in newborns and infants due to their functionally insufficient immune system 4

Safety Profile

• Only antihistamines with proven efficacy and safety should be used in newborns and infants 4
• Second-generation antihistamines generally have excellent safety profiles with no dose-dependent increase in adverse effects at higher doses 8
• There were no reports of systemic complications, including cardiotoxicity, at higher than licensed doses of second-generation antihistamines 8

When to Escalate Beyond First-Line Therapy

Second-Line: Omalizumab

• For chronic spontaneous urticaria unresponsive to high-dose antihistamines (up to 4 times standard dose), consider omalizumab at 300 mg subcutaneously every 4 weeks 1, 3, 2
• Allow up to 6 months to evaluate response before considering alternative treatments 1, 2

Third-Line: Cyclosporine

• Cyclosporine at 4 mg/kg per day for a maximum of 2 months is recommended for patients who fail both high-dose antihistamines and omalizumab 1, 2
• This is effective in approximately two-thirds of patients with severe autoimmune urticaria 1
• Regular monitoring of blood pressure and renal function every 6 weeks is required 1

Emergency Management

Life-Threatening Presentations

• Intramuscular epinephrine is life-saving in anaphylaxis and severe laryngeal angioedema 1
• Dosing is weight-dependent: auto-injector pens deliver 300 µg for adults/adolescents or 150 µg for children weighing 15-30 kg 1
• If no significant relief after the first dose, administer an additional dose of epinephrine 1
• When urticaria is associated with anaphylaxis, use intramuscular epinephrine together with antihistamines and steroids (plus fluids and bronchodilators if required) 9

Prognosis

• Approximately 50% of children with chronic urticaria presenting with wheals alone will be symptom-free within 6 months 1, 2
• Patients with both wheals and angioedema have a poorer prognosis, with over 50% still having active disease after 5 years 1, 2