What is the recommended treatment for a patient presenting with urticaria?

Treatment of Urticaria

Start with second-generation H1 antihistamines at standard doses, and if inadequate after 2-4 weeks, increase up to 4 times the standard dose before considering additional therapies. 1, 2

First-Line Treatment: Second-Generation H1 Antihistamines

• Begin with a single second-generation H1 antihistamine such as cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine at standard dosing 1, 2
• Offer patients a choice of at least two different non-sedating antihistamines, as individual responses and tolerance vary significantly 3, 1
• Second-generation agents are preferred over first-generation antihistamines due to superior safety profiles and reduced sedation 1
• Continue standard dosing for 2-4 weeks to assess response 1, 4

Dose Escalation Strategy

• If symptoms remain inadequately controlled after 2-4 weeks, increase the antihistamine dose up to 4 times the standard dose 3, 1, 4
• This updosing approach has become common practice when potential benefits outweigh risks, though it exceeds manufacturer's licensed recommendations 3, 4
• Over 40% of patients with urticaria show good response to antihistamines at appropriate doses 3

Adjunctive Therapies for Resistant Cases

When updosed second-generation antihistamines provide insufficient control, consider these additions:

• Add a first-generation H1 antihistamine at bedtime (such as hydroxyzine) for additional symptom control and sleep improvement 3, 4
• Add H2 antihistamines (ranitidine or famotidine) for resistant cases 3, 4
• Add leukotriene receptor antagonists (montelukast) as adjunctive therapy, particularly beneficial for aspirin-sensitive and autoimmune urticaria 1, 4

Role of Corticosteroids

• Restrict oral corticosteroids to short courses only for severe acute urticaria or life-threatening angioedema affecting the airway 3, 4
• Avoid prolonged corticosteroid use due to cumulative toxicity including hypertension, hyperglycemia, osteoporosis, and gastric complications 4
• Exceptions include delayed pressure urticaria or urticarial vasculitis, which may require more prolonged treatment 3

Second-Line Treatment: Omalizumab

• For chronic spontaneous urticaria unresponsive to high-dose antihistamines, use omalizumab 300 mg subcutaneously every 4 weeks 1, 4, 2, 5
• Omalizumab is FDA-approved for adults and adolescents ≥12 years with chronic spontaneous urticaria who remain symptomatic despite H1 antihistamine treatment 5
• Allow up to 6 months for response assessment 4
• In clinical trials, 36% of patients treated with omalizumab 300 mg achieved complete symptom resolution (no itch, no hives) at Week 12 compared to 9% with placebo 5
• Omalizumab is NOT indicated for physical urticarias or other forms of urticaria - only chronic spontaneous urticaria 5

Third-Line Treatment: Cyclosporine

• For severe autoimmune urticaria failing omalizumab after 6 months, use cyclosporine 2.5-5 mg/kg/day divided twice daily 4, 2
• Approximately 65-70% of patients with severe autoimmune urticaria respond to cyclosporine 4
• Restrict immunomodulating therapies to patients with disabling disease who have not responded to optimal conventional treatments 3

General Measures and Trigger Avoidance

• Identify and minimize aggravating factors including overheating, stress, and alcohol 3, 4
• Avoid aspirin and NSAIDs, as they inhibit cyclooxygenase and can exacerbate urticaria 4
• Avoid codeine and other drugs with potential to worsen urticaria 3
• Avoid ACE inhibitors if angioedema is present without wheals, and use cautiously when angioedema accompanies urticaria 4
• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 1

Special Considerations for Physical Urticarias

• Physical urticaria wheals typically resolve within 1 hour (except delayed pressure urticaria, which can last up to 48 hours) 1
• Treatment follows the same antihistamine-based algorithm as ordinary urticaria 1
• In cholinergic urticaria, focus on avoiding core temperature increases 1

Distinguishing Urticarial Vasculitis

• If individual wheals persist beyond 24 hours, consider urticarial vasculitis and obtain a skin biopsy 4, 2
• Urticarial vasculitis requires different management and has lesions that often leave bruising or hyperpigmentation 1, 2

Emergency Management

• Administer intramuscular epinephrine 0.5 mL of 1:1000 immediately for severe urticaria with anaphylaxis or angioedema affecting the airway 4
• Omalizumab carries a black box warning for anaphylaxis risk; initiate therapy in a healthcare setting with appropriate observation period 5

Monitoring and Treatment Duration

• Regularly assess disease activity, impact on quality of life, and treatment response 1
• After achieving complete symptom control for at least 3 consecutive months, consider stepping down therapy 1
• Reduce daily dose gradually, no more than 1 tablet per month 1
• If symptoms recur during step-down, return to the last effective dose that provided complete control 1

Prognosis

• Approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 3, 4
• Patients with both wheals and angioedema have a poorer prognosis, with over 50% still having active disease after 5 years 3, 4