What is the treatment for an 11-year-old patient presenting with urticaria (hives) on their face?

Treatment for an 11-Year-Old with Facial Hives

Start with cetirizine 10 mg once daily or loratadine 10 mg once daily as first-line treatment for this 11-year-old with facial urticaria. 1, 2

First-Line Treatment: Non-Sedating Antihistamines

• Second-generation H1 antihistamines are the mainstay of therapy for acute urticaria in children and adolescents, with cetirizine and loratadine being the preferred agents 1, 2
• Offer the patient a choice between cetirizine 10 mg daily or loratadine 10 mg daily, as individual responses vary significantly between agents 2
• Cetirizine has the shortest time to reach maximum concentration, making it advantageous for rapid symptom relief 2
• Alternative options include fexofenadine 30 mg twice daily (for ages 2-11 years), desloratadine, or levocetirizine 1, 3

Adjunctive Topical Treatment for Facial Hives

• For facial involvement, add a low-potency topical corticosteroid (Class V or VI) if needed, such as hydrocortisone 1% cream applied to affected areas 3-4 times daily 1, 4
• The face requires lower-potency steroids than the body due to increased absorption and thinner skin 1
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide additional symptomatic relief 1, 2

Dose Escalation Strategy if Inadequate Response

• Assess response after 2-4 weeks of standard antihistamine dosing 1, 2
• If symptoms persist, increase the antihistamine dose up to 4 times the standard dose when benefits outweigh risks (e.g., cetirizine 20-40 mg daily) 1, 2
• For children, dose escalation up to twice the standard dose is generally recommended, though up to 4-fold increases are supported when necessary 2, 3

When to Consider Systemic Corticosteroids

• Reserve oral corticosteroids for severe cases (>30% body surface area involvement) or inadequate response to increased antihistamine dosing 1
• If needed, use prednisone 0.5-1 mg/kg/day (approximately 20-40 mg daily for an 11-year-old) until hives resolve 1
• Limit corticosteroids to 3-10 days only for severe acute exacerbations; avoid long-term use 2

Critical Safety Considerations

• Prescribe an epinephrine autoinjector if there is any concern for angioedema affecting the airway or potential anaphylaxis 5, 2
• Assess for airway compromise, particularly if there is lip, tongue, or throat swelling 1
• Antihistamines should be used for mild symptoms (a few hives, mild discomfort), while epinephrine is reserved for severe symptoms including respiratory involvement or obstructive swelling 5, 2

Identify and Minimize Aggravating Factors

• Look for specific triggers in the history: recent foods (especially the "big 8" allergens), medications (aspirin, NSAIDs, codeine), infections, or environmental exposures 1, 2
• Advise avoiding overheating, stress, and alcohol, which can worsen urticaria 1, 2
• Have parents keep a diary of foods and exposures before breakouts if the pattern is unclear 5

When to Refer or Escalate

• If symptoms persist beyond 6 weeks despite treatment, the patient has chronic urticaria and should be referred to an allergist or dermatologist 2
• Consider same-day dermatology consultation for severe cases with extensive involvement 1
• Do not perform extensive laboratory testing for acute urticaria unless symptoms persist beyond 6 weeks or specific systemic disease is suspected 2

Common Pitfalls to Avoid

• Avoid first-generation sedating antihistamines (like diphenhydramine) as primary therapy due to sedation, impaired concentration, and only marginal onset-of-action advantage over second-generation agents 3, 6
• Do not underdose antihistamines—many patients require higher than standard doses for adequate control 7
• Do not use antihistamines in place of epinephrine for severe reactions with respiratory symptoms 5, 2
• Avoid long-term systemic corticosteroids, which should be reserved only for short courses in severe acute cases 2