What is the initial treatment for a patient with hives and no hemodynamic instability?

Treatment of Hives Without Hemodynamic Instability

Start immediately with a second-generation non-sedating H1 antihistamine at standard dosing—cetirizine 10 mg, fexofenadine 180 mg, desloratadine 5 mg, levocetirizine 5 mg, or loratadine 10 mg—as this is the definitive first-line treatment for urticaria. 1, 2

Immediate Assessment and Initial Treatment

• Confirm the patient is hemodynamically stable with normal vital signs and has no respiratory symptoms, throat tightness, or gastrointestinal symptoms that would indicate anaphylaxis requiring epinephrine 3
• Assess the severity of hives: mild (<10% body surface area), moderate (10-30% body surface area), or severe (>30% body surface area) 3
• Administer a second-generation non-sedating H1 antihistamine immediately at standard dosing 1, 2
• Offer the patient at least two different non-sedating antihistamines to trial, as individual responses and tolerance vary significantly 1, 2
• Choose cetirizine if rapid symptom relief is needed, as it reaches maximum concentration fastest among the second-generation antihistamines 1, 2

Symptomatic Relief Measures

• Apply cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream for immediate symptomatic relief of itching 2, 3
• Identify and counsel the patient to avoid aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1, 2
• Avoid NSAIDs in all urticaria patients, as they can trigger or worsen urticaria 2, 3

Critical Management Pitfalls to Avoid

Never use corticosteroids as first-line treatment for simple hives without hemodynamic instability. 1, 2 Corticosteroids have slow onset of action (working by inhibiting gene expression), are ineffective for acute symptom relief, and should be restricted to short courses only for severe acute urticaria or angioedema 1, 2

• Antihistamines remain the first-line therapy; the more H1-receptors blocked, the better the results, and the majority of urticaria patients are undertreated 4
• Steroids are rarely warranted for management of uncomplicated urticaria 4, 5
• Systemic corticosteroids should never be used as maintenance therapy for chronic urticaria 2
• Long-term or repeated corticosteroid courses risk adrenal suppression, growth interference in children, dermal thinning, hypertension, diabetes, Cushing syndrome, cataracts, muscle weakness, and impaired immune function 2, 6

Escalation Strategy if Initial Treatment Fails

• If symptoms persist after 2-4 weeks on standard dosing, increase the antihistamine dose up to 4 times the standard dose before adding other therapies 1, 2
• For moderate hives unresponsive to standard dosing, add a sedating antihistamine at bedtime such as hydroxyzine 10-25 mg 3
• Reserve systemic corticosteroids (prednisone 0.5-1 mg/kg/day) only for severe hives until resolution 3

Observation and Discharge Criteria

• Observe the patient for at least 1-2 hours after symptom resolution before discharge 7
• Patients with minimal residual symptoms such as a few new hives or swollen lips may be discharged after 4 hours of observation 7
• Provide an emergency treatment plan and medications on discharge, including oral antihistamines for continued use 7
• Counsel patients about the low potential risk of delayed reactions hours later and provide means to contact the physician 7

When to Consider Alternative Diagnoses

• If individual wheals persist >24 hours at one site, consider urticarial vasculitis and perform a lesional skin biopsy 3, 8
• If the rash does not respond to antihistamines or persists longer than 24-36 hours at one site, consider alternative inflammatory processes 8
• Perform a full vasculitis screen including serum complement assays for C3 and C4 if urticarial vasculitis is suspected 2