Prescription Treatment for a 13-Year-Old with Itchy Hives
Start with a second-generation non-sedating H1 antihistamine such as cetirizine 10 mg once daily or loratadine 10 mg once daily as first-line therapy for urticaria in this adolescent patient. 1, 2, 3
First-Line Treatment: Non-Sedating Antihistamines
Prescribe one of the following second-generation H1 antihistamines at standard dosing: 1, 2, 3
- Cetirizine 10 mg once daily
- Loratadine 10 mg once daily 4
- Desloratadine 5 mg once daily
- Fexofenadine 180 mg once daily
- Levocetirizine 5 mg once daily
Offer the patient a choice between at least two different antihistamines, as individual responses and tolerance vary significantly between agents 1, 2, 3
Cetirizine has the shortest time to reach maximum concentration, making it advantageous for rapid symptom relief 2
Avoid first-generation antihistamines (diphenhydramine, hydroxyzine) as primary therapy due to significant sedation and anticholinergic effects, though they may be added at bedtime if additional symptom control is needed 3, 5
Dose Escalation Strategy
If symptoms are not adequately controlled after 2-4 weeks at standard dosing, increase the antihistamine dose up to 4 times the standard dose 1, 2, 3, 6
This approach (e.g., cetirizine 40 mg daily or loratadine 40 mg daily) improves symptoms in approximately 75% of patients with difficult-to-treat urticaria without compromising safety 6
Increasing antihistamine doses improves quality of life without increasing somnolence 6
Adjunctive Measures for Acute Management
For severe acute urticaria with inadequate response to antihistamines alone, consider a short course of oral corticosteroids (e.g., prednisolone 50 mg daily for 3 days, adjusted for pediatric weight) 2
Limit corticosteroids to 3-10 days only for severe acute exacerbations; long-term use should be avoided 2
Prescribe both antihistamines and an epinephrine autoinjector if there is any concern for potential anaphylaxis or severe angioedema involving the airway 7, 2
General Measures and Trigger Avoidance
Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1, 2, 3
Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 2
Control environmental temperature through rational use of bathing, showering, swimming, and air conditioning to decrease mediator release and reduce the need for higher antihistamine doses 2
When to Refer or Escalate Treatment
If symptoms persist beyond 6 weeks despite high-dose antihistamines, the patient has chronic spontaneous urticaria and should be referred to an allergist or dermatologist 2, 3
Second-line therapy for chronic urticaria unresponsive to quadrupled antihistamine doses is omalizumab 300 mg subcutaneously every 4 weeks 1, 2, 3
Third-line therapy is cyclosporine 4 mg/kg daily for up to 2 months, reserved for specialist management 1, 2, 3
Important Caveats
Do not perform extensive laboratory testing for acute urticaria; testing is only indicated if symptoms persist beyond 6 weeks or if specific systemic disease is suspected based on history and physical examination 2, 3
Approximately 50% of patients with chronic urticaria presenting with only hives will be symptom-free within 6 months 2
Antihistamines should be used for mild symptoms (a few hives, mild discomfort), while epinephrine is reserved for severe symptoms including diffuse hives, respiratory symptoms, or angioedema affecting breathing 7