Initial Treatment for Hives (Urticaria)
Start with a second-generation non-sedating H1 antihistamine at standard dosing as first-line therapy for all patients presenting with hives. 1, 2, 3
First-Line Treatment Approach
Begin with one of these second-generation antihistamines:
- Cetirizine 10 mg once daily (fastest onset—reaches maximum concentration quickest) 1, 4
- Loratadine 10 mg once daily 4
- Fexofenadine 180 mg once daily 1
- Desloratadine 5 mg once daily 1
- Levocetirizine 5 mg once daily 1
Key advantage: These medications are non-sedating and should be used for daytime management, unlike first-generation antihistamines (diphenhydramine, hydroxyzine) which cause significant sedation and cognitive impairment without superior efficacy. 1, 5
Dose Escalation Strategy (If Inadequate Response)
If symptoms persist after 2-4 weeks on standard dosing, increase the antihistamine dose up to 4 times the standard dose. 1, 4 For example:
- Cetirizine can be increased to 20 mg once daily, then up to 40 mg daily if needed 4
- This approach is supported by guidelines when benefits outweigh risks 4
Patients should trial at least two different non-sedating antihistamines, as individual responses and tolerance vary. 1
Severity-Based Treatment Algorithm
Mild Hives (<10% body surface area):
- Continue standard-dose oral antihistamine 4
- Add topical corticosteroids if needed (Class I for body, Class V/VI for face) 4
Moderate Hives (10-30% body surface area):
- Increase antihistamine dose up to 4-fold the standard dose 4
- Continue oral antihistamines (cetirizine/loratadine 10 mg daily) 4
Severe Hives (>30% body surface area):
- Add systemic corticosteroids: prednisone 0.5-1 mg/kg/day until hives resolve 4
- Critical caveat: Systemic corticosteroids should NEVER be used as maintenance therapy for chronic urticaria—only for short-term control during acute flares 1
- Consider same-day dermatology consultation 4
When to Use Epinephrine
Epinephrine injection is the preferred treatment for systemic hives with organ involvement: 6
- Upper or lower airway compromise
- Gastrointestinal symptoms
- Neurologic symptoms
- Cardiovascular involvement
- Acute anaphylaxis with hypotension, laryngeal edema, vasomotor collapse, oxygen desaturation, or seizures
For systemic hives WITHOUT organ involvement, antihistamines alone are sufficient. 6
Adjunctive Measures
Identify and minimize aggravating factors: 1, 4
- Overheating, stress, alcohol
- Avoid NSAIDs and aspirin (especially in aspirin-sensitive patients) 1
- Avoid codeine 1, 4
For symptomatic relief:
- Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) 1, 4
- Regular emollients for associated dry skin 1
Nighttime Management
For nighttime itching interfering with sleep, add hydroxyzine at bedtime while continuing non-sedating antihistamines during the day. 5 This leverages the sedative properties of first-generation antihistamines specifically when beneficial, while avoiding daytime cognitive impairment.
Important Caveats
Avoid first-generation antihistamines (diphenhydramine, hydroxyzine) as first-line daytime therapy due to sedation and cognitive impairment without superior efficacy compared to second-generation agents. 1
Do not use topical crotamiton cream or capsaicin for urticaria—evidence does not support their use. 1
Assess for angioedema: If present, evaluate for airway compromise and consider epinephrine for severe symptoms affecting breathing. 4
When to Refer or Escalate
If patients fail to respond adequately to high-dose antihistamines (up to 4-fold standard dosing) after appropriate trial: