What can be ordered besides prednisone for a patient presenting with hives and pruritus?

Treatment Options for Hives and Itching Beyond Prednisone

Second-generation non-sedating H1-antihistamines are the definitive first-line treatment for urticaria with pruritus, with doses that can be increased up to four times the standard dose if initial therapy fails. 1, 2

First-Line Pharmacotherapy: Non-Sedating Antihistamines

Start with one of these second-generation H1-antihistamines at standard dosing 1, 3, 2:

• Loratadine 10 mg once daily 3
• Fexofenadine 180 mg once daily 4, 3
• Cetirizine 10 mg once daily (has shortest time to maximum concentration for rapid relief) 2
• Levocetirizine 5 mg once daily 2
• Desloratadine 5 mg once daily 2

If inadequate response after 1 week, increase the dose up to 4-fold (e.g., cetirizine 40 mg daily, fexofenadine 720 mg daily) before switching agents. 2, 5 This approach improves symptoms in approximately 75% of patients with difficult-to-treat urticaria without compromising safety. 5

Try at least two different non-sedating antihistamines before escalating therapy, as individual responses vary significantly. 2

Enhanced Antihistamine Strategy

Consider combining H1 and H2 antagonists for refractory cases 4, 3:

• Fexofenadine 180 mg daily PLUS cimetidine (H2-blocker) 4
• This combination may provide enhanced antipruritic effect beyond H1-blockade alone 4

Topical Adjunctive Therapy

Apply emollients regularly to all affected areas, particularly high-lipid content formulations to restore skin barrier function. 4, 3, 2

For localized areas, consider:

• Moderate-potency topical corticosteroids (mometasone furoate 0.1% or betamethasone valerate 0.1% ointment) 3
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) 2
• Clobetasone butyrate 4

Short-Term Corticosteroid Use (When Absolutely Necessary)

If you must use systemic corticosteroids, use them only as a brief bridge therapy 1, 2:

• Prednisolone 40-50 mg daily for 3 days maximum in adults 1
• Never use as maintenance therapy for chronic urticaria 2
• Short tapering courses over 3-4 weeks may be necessary only for urticarial vasculitis or severe delayed pressure urticaria 1

Second-Line Systemic Agents (If Antihistamines Fail)

For nighttime sedation and antihistamine-resistant cases, consider doxepin 3:

• Doxepin 10 mg orally twice daily (functions as both tricyclic antidepressant and potent H1/H2 antagonist) 3
• Drowsiness occurs in 50% but typically resolves within 2 days 3
• Avoid long-term use except in palliative settings due to dementia risk 3

For refractory cases unresponsive to high-dose antihistamines 2:

• Omalizumab 300 mg subcutaneously every 4 weeks (anti-IgE monoclonal antibody) 2
• Allow up to 6 months for response before considering alternatives 2

For severe autoimmune urticaria failing omalizumab 2, 6:

• Cyclosporine 4 mg/kg daily for up to 2 months 1, 2
• Requires monitoring of blood pressure and renal function every 6 weeks 2, 6
• Effective in approximately two-thirds of patients 1, 2

Critical Pitfalls to Avoid

Do NOT use first-generation sedating antihistamines (diphenhydramine, hydroxyzine) as first-line therapy 2:

• They cause significant sedation and cognitive impairment without superior efficacy 2
• Long-term use predisposes to dementia, especially in elderly patients 4, 3
• Reserve only for short-term nighttime use if absolutely necessary 3

Do NOT use topical crotamiton cream or capsaicin for urticaria - evidence does not support their use. 4, 2

Avoid NSAIDs and aspirin in patients with urticaria, as they commonly aggravate symptoms. 2

Practical Treatment Algorithm

1. Start: Non-sedating H1-antihistamine (loratadine 10 mg or fexofenadine 180 mg) + emollients 4, 3, 2
2. Week 1-2: If inadequate response, increase to 2-4x standard dose 2, 5
3. Week 2-4: If still inadequate, switch to different non-sedating antihistamine or add H2-blocker 4, 3, 2
4. Week 4+: Consider doxepin 10 mg BID for nighttime symptoms 3
5. Refractory: Omalizumab 300 mg every 4 weeks (allow 6 months for response) 2
6. Last resort: Cyclosporine with appropriate monitoring 2, 6

Use prednisone only as a 3-day bridge during severe acute flares, never as maintenance therapy. 1, 2