Can a Patient with Acute Urticaria Start with Prednisone?
No, prednisone should not be the initial treatment for acute urticaria—start with second-generation H1 antihistamines first, and reserve prednisone 50 mg daily for 3 days only for severe cases that fail antihistamine therapy or cover >30% body surface area. 1, 2, 3
Initial Treatment Approach
Begin with second-generation H1 antihistamines (cetirizine, loratadine, fexofenadine, levocetirizine, desloratadine) at standard doses for 2-4 weeks, as more than 40% of patients respond to antihistamines alone. 1, 2
Antihistamines should be used regularly, not just after hives appear, to maintain consistent mast cell stabilization. 4
The newer non-sedating antihistamines are strongly preferred over first-generation sedating antihistamines due to superior safety profiles without compromising efficacy. 5
When to Escalate to Corticosteroids
Add prednisone only when:
- Antihistamines fail to control severe acute urticaria after initial trial 1, 2
- Urticaria covers >30% body surface area 3
- Symptoms are intolerable despite antihistamine therapy 2
The guideline-recommended regimen is prednisone 50 mg daily for 3 days (adjust proportionally for pediatric patients based on weight: 0.5-1 mg/kg/day). 1, 2, 3
Evidence Supporting This Approach
The evidence for adding corticosteroids to antihistamines in acute urticaria is surprisingly weak. A 2024 systematic review found that adding prednisone to antihistamines did not improve symptoms compared to antihistamines alone in 2 out of 3 randomized controlled trials. 6 Despite this limited evidence, guidelines still recommend short-course prednisone for severe cases based on clinical experience and the need for rapid symptom control. 1
Lower corticosteroid doses are frequently effective and should be considered to minimize exposure and adverse effects. 1, 2
Dose Escalation Algorithm Before Steroids
If inadequate response after 2-4 weeks of standard-dose antihistamines:
- Increase antihistamine dose up to 4 times the standard dose (e.g., cetirizine from 10 mg to 40 mg daily) before adding corticosteroids. 1, 2
- Approximately 75% of patients respond to antihistamine dose escalation, avoiding the need for steroids entirely. 2
Critical Pitfalls to Avoid
Never use corticosteroids as first-line treatment when antihistamines are sufficient—this is the most common error in acute urticaria management. 1, 2
Never continue corticosteroids beyond 3-10 days due to cumulative toxicity without sustained benefit. 1, 2
Never use chronic corticosteroids for chronic spontaneous urticaria (lasting >6 weeks) except in very selected cases under regular specialist supervision—this leads to significant morbidity from steroid toxicity. 1, 2, 3
Avoid methylprednisolone or dexamethasone as routine choices; prednisolone 50 mg daily for 3 days is the guideline-specified regimen. 1
Management of Chronic or Refractory Cases
If urticaria becomes chronic (>6 weeks) and remains unresponsive to high-dose antihistamines:
Escalate to omalizumab 300 mg subcutaneously every 4 weeks (preferred second-line agent) rather than chronic corticosteroids. 1, 2, 3
Alternatively, cyclosporine 4 mg/kg daily for up to 2 months is effective in approximately two-thirds of severe autoimmune urticaria cases. 1, 2, 3
Short-term systemic corticosteroids may be considered for acute exacerbations, but long-term use should never be employed. 7
Emergency Considerations
Assess for airway compromise if angioedema is present—this requires immediate epinephrine 0.5 mL of 1:1000 (500 µg) intramuscularly, not antihistamines or corticosteroids. 2, 3
Prescribe epinephrine autoinjector for patients with severe symptoms including diffuse hives with respiratory symptoms or obstructive swelling of tongue/lips. 3