What is the management of urticarial (hives) rash?

From the Guidelines

Management of urticarial rash primarily involves antihistamines as first-line treatment, with second-generation H1 antihistamines like cetirizine 10mg daily, loratadine 10mg daily, or fexofenadine 180mg daily being preferred due to their minimal sedating effects. For severe or persistent cases, dosing can be increased up to four times the standard dose 1.

Key Considerations

• Acute urticaria episodes may benefit from a short course of oral corticosteroids such as prednisone 40-60mg daily for 3-5 days to quickly reduce inflammation 1.
• Avoiding identified triggers is essential, including certain foods, medications, physical stimuli, or environmental factors.
• For immediate relief of itching and discomfort, cool compresses and wearing loose-fitting cotton clothing can help.
• In cases of angioedema or respiratory symptoms, epinephrine auto-injectors should be available for emergency use.
• For chronic urticaria lasting beyond six weeks, additional therapies may include omalizumab, cyclosporine, or leukotriene receptor antagonists like montelukast 10mg daily 1.

Treatment Approach

• The treatment approach should be guided by the Urticaria Control Test (UCT) and the Angioedema Control Test (AECT) to assess disease control and guide treatment decisions 1.
• The goal of treatment is to provide patients with complete control of their disease, which may require one or more changes in treatment.
• A step-up and step-down approach should be used, with treatment intensified or reduced based on the patient's response and disease control.

Monitoring and Follow-up

• Regular monitoring of disease control and treatment response is essential to adjust the treatment plan as needed.
• Patients should be educated on the importance of adhering to their treatment plan and seeking medical attention if their symptoms worsen or if they experience any adverse effects.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Urticarial Rash Management

• Urticaria is a common skin condition characterized by intensely pruritic wheals, sometimes with edema of the subcutaneous or interstitial tissue, with a lifetime prevalence of about 20% 2.
• The mainstay of treatment is avoidance of triggers, if identified, and the first-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses 2, 3.
• First-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, high-potency antihistamines, and brief corticosteroid bursts may be used as adjunctive treatment 2, 4.
• For chronic idiopathic urticaria, loratadine or cetirizine, and possibly mizolastine, appear to be treatments of choice 3.
• In refractory chronic urticaria, patients can be referred to subspecialists for additional treatments, such as omalizumab or cyclosporine 2, 5.
• Non-pharmacotherapeutic means to minimize hyper-responsive skin are also important and recommended, such as prevention skin from drying, avoidance of hot shower, scrubbing, and excessive sun exposure 5.
• Leukotriene receptor antagonists as adjuvant therapy of antihistamines in chronic urticaria do not have better outcomes than antihistamines alone regarding TSS and pruritus in patients with CU 6.

Treatment Options

• Second-generation H1 antihistamines: acrivastine, cetirizine, loratadine, mizolastine, fexofenadine, ebastine, azelastine, and epinastine 3.
• First-generation H1 antihistamines: chlorpheniramine and hydroxyzine 3.
• H2 antihistamines: ranitidine, cimetidine, and famotidine 3, 4.
• Leukotriene receptor antagonists: may be used as adjunctive treatment, but do not have better outcomes than antihistamines alone regarding TSS and pruritus in patients with CU 6.

Special Considerations

• Anaphylaxis must be ruled out in the diagnosis of urticaria 2.
• Chronic urticaria is idiopathic in 80% to 90% of cases, and only a limited nonspecific laboratory workup should be considered unless elements of the history or physical examination suggest specific underlying conditions 2.
• Angioedema either alone or with urticaria is associated with a much lower remission rate, and proper investigation and treatment is thus required 5.