What is the best treatment approach for a 16-year-old patient presenting with urticaria (hives), fever, common cold symptoms, and cough?

Treatment for Skin Hives in a 16-Year-Old with Fever, Colds, and Cough

Start with a second-generation antihistamine like cetirizine 10 mg daily as first-line treatment for the acute urticaria, and reserve oral corticosteroids only for severe cases covering >30% body surface area or when antihistamines fail to control symptoms. 1

Initial Assessment and Diagnosis

The clinical presentation suggests acute urticaria occurring in the context of a viral upper respiratory infection (common cold). This is the most common trigger for acute episodic urticaria in adolescents. 2

• Rule out anaphylaxis first: Assess immediately for respiratory compromise (wheezing, stridor, difficulty breathing), hypotension, or persistent gastrointestinal symptoms (vomiting, abdominal pain). 3
• If any of these features are present, this is anaphylaxis requiring intramuscular epinephrine 0.3 mg in the anterolateral thigh, not antihistamines alone. 3, 4
• The fever, colds, and cough indicate a viral upper respiratory infection, which is a well-established trigger for acute urticaria in this age group. 2

First-Line Treatment: Antihistamines

For uncomplicated acute urticaria (hives only, no respiratory or cardiovascular symptoms):

• Prescribe a second-generation, non-sedating H1-antihistamine such as cetirizine 10 mg once daily or loratadine 10 mg once daily. 1, 5
• These are superior to first-generation antihistamines (diphenhydramine, hydroxyzine) because they avoid significant sedation and cognitive impairment while providing equivalent or better efficacy. 3
• Do not use newer-generation non-sedating antihistamines alone for the common cold symptoms, as they are relatively ineffective for cold symptoms. 3

For the concurrent cold and cough symptoms:

• A first-generation antihistamine/decongestant combination can be effective for reducing cough associated with viral upper respiratory infection. 3
• Alternatively, naproxen (Naprosyn) has been shown to decrease cough, headache, malaise, and myalgia in common cold, unless contraindicated. 3

Escalation Based on Severity

Mild urticaria (<10% body surface area):

• Continue standard-dose oral antihistamines (cetirizine 10 mg daily). 1

Moderate urticaria (10-30% body surface area) or inadequate response to standard dosing:

• Increase antihistamine dose up to 4 times the standard dose (cetirizine up to 40 mg daily). 1, 6
• This updosing is safe and recommended before adding corticosteroids. 1

Severe urticaria (>30% body surface area) or failure of high-dose antihistamines:

• Add oral corticosteroids: prednisone 0.5-1 mg/kg/day (approximately 30-60 mg for a typical 16-year-old) for 3 days until hives resolve. 1, 7
• Prednisone is FDA-approved for "control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment" including drug hypersensitivity reactions and serum sickness. 7
• Administer in the morning (before 9 am) to minimize HPA axis suppression. 7

Critical Pitfalls to Avoid

• Never delay epinephrine if anaphylaxis is present: Antihistamines do not relieve upper airway edema or shock and are not first-line therapy for anaphylaxis. 3, 4
• Do not prescribe antibiotics: The cough and cold are viral, and antibiotics are not indicated for acute cough from the common cold or acute bronchitis. 3
• Do not use long-term corticosteroids: If urticaria persists beyond 6 weeks (chronic urticaria), corticosteroids should never be used long-term except in very selected cases under specialist supervision. 1
• Do not use first-generation antihistamines as first-line for urticaria: They cause excessive sedation without superior efficacy compared to second-generation agents. 3

Expected Course and Follow-Up

• Acute urticaria associated with viral infection typically improves progressively over 1-2 weeks as the viral illness resolves. 3
• If symptoms worsen after initial improvement (biphasic course) or do not steadily improve after the first week, consider bacterial sinusitis or other complications requiring different treatment. 3
• If urticaria persists beyond 6 weeks, refer to allergist/immunologist for evaluation of chronic spontaneous urticaria. 4, 6

Emergency Prescriptions

If severe urticaria or any concern for potential anaphylaxis:

• Prescribe epinephrine autoinjector (0.3 mg for adolescents) with proper training on use. 3, 4
• Instruct patient to use immediately for any respiratory symptoms, difficulty breathing, or swelling of tongue/lips interfering with breathing. 3