What is the management of periorbital edema related to urticaria (hives)?

From the Guidelines

Management of periorbital swelling related to urticaria requires prompt intervention with antihistamines as first-line treatment, specifically starting with second-generation H1 antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) for immediate relief with minimal sedation, as recommended by the most recent guidelines 1.

Key Considerations

• The treatment approach should be stepped up or down based on the level of disease control, assessed using the Urticaria Control Test (UCT) score, with the goal of using "as much as needed and as little as possible" treatment 1.
• For severe cases, adding H2 blockers such as ranitidine (150mg twice daily) or famotidine (20mg twice daily) may enhance effectiveness, although the primary treatment remains antihistamines 1.
• Oral corticosteroids like prednisone (20-40mg daily for 3-5 days) may be necessary for significant swelling that doesn't respond to antihistamines, but their use should be limited due to potential side effects 1.

Additional Measures

• Apply cold compresses to the affected area for 10-15 minutes several times daily to reduce swelling and discomfort.
• Keep the patient in a semi-upright position to minimize fluid accumulation around the eyes.
• Identify and avoid potential triggers such as foods, medications, or environmental factors.
• If breathing difficulties, throat tightness, or significant visual changes occur, seek emergency care immediately as these may indicate anaphylaxis or severe angioedema.

Treatment Adjustment

• The treatment should be adjusted based on the patient's response, with options to increase the dose of antihistamines up to 4-fold higher than standard doses if necessary, or to add other treatments like omalizumab for patients who do not respond to higher doses of antihistamines 1.
• The use of omalizumab, with a recommended starting dose of 300 mg every 4 weeks, and the option to updose if necessary, provides an additional treatment option for patients with severe chronic urticaria 1.

From the FDA Drug Label

Epinephrine also alleviates pruritus, urticaria, and angioedema and may relieve gastrointestinal and genitourinary symptoms associated with anaphylaxis because of its relaxer effects on the smooth muscle of the stomach, intestine, uterus and urinary bladder The management of periorbital swelling related to urticaria may be alleviated by epinephrine (IM) as it alleviates urticaria and angioedema 2.

• Key points:
  • Epinephrine has a rapid onset and short duration of action
  • It acts on both alpha and beta-adrenergic receptors to alleviate symptoms of anaphylaxis, including urticaria and angioedema However, prednisone (PO) may also be considered for the management of urticaria as it is listed as an adverse reaction that can be associated with the drug, implying it may be used to treat the condition, but the label does not directly address periorbital swelling related to urticaria 3.

From the Research

Management of Periorbital Swelling Related to Urticaria

• Periorbital swelling is a common symptom of urticaria, which can be acute or chronic 4, 5.
• The management of periorbital swelling related to urticaria involves a step-wise approach, starting with the use of non-sedating H1-antihistamines as the first-line treatment for 2-4 weeks 4.
• If the symptoms are not controlled, increasing the dose of antihistamines up to 4 times is recommended 4.
• Second-generation, non-sedating histamine type 1 (H1)-receptor antihistamines, such as loratadine or cetirizine, are preferred due to their reduced sedative and anticholinergic effects 6.
• In cases of chronic urticaria, omalizumab, an anti-IgE antibody, can be considered as an alternative treatment option, although its high cost may limit its accessibility in low-middle income countries 4, 5.
• Non-pharmacotherapeutic measures, such as preventing skin from drying, avoiding hot showers, scrubbing, and excessive sun exposure, can also help minimize hyper-responsive skin and reduce periorbital swelling 4.
• In severe cases, where angioedema involves the respiratory tract, urgent treatment with systemic corticosteroids and other medications may be necessary to prevent life-threatening complications 7.