Treatment of Hives (Urticaria)
Start with a second-generation non-sedating H1 antihistamine as first-line therapy: cetirizine 10 mg, loratadine 10 mg, fexofenadine 180 mg, or levocetirizine 5 mg once daily. 1
First-Line Treatment: Non-Sedating Antihistamines
Begin with standard-dose second-generation H1 antihistamines as the mainstay of therapy for isolated hives without organ involvement 1, 2
Specific options include:
Offer at least two different non-sedating antihistamines as options, since individual responses and tolerance vary significantly 3, 5
Dose Escalation if Inadequate Response
- If symptoms persist after 24-48 hours, increase the antihistamine dose up to 4 times the standard dose when benefits outweigh risks 1, 2, 5
- Example: cetirizine can be increased from 10 mg to 20-40 mg daily 2
- This updosing is common practice despite exceeding manufacturer's licensed recommendations 3
- Adjust timing of medication to ensure highest drug levels coincide with anticipated urticaria episodes 3
Adjunctive Therapy for Enhanced Control
- Add an H2 antihistamine (ranitidine 75-150 mg twice daily or cimetidine) to the H1 antihistamine for superior symptom control 1, 5
- The combination of H1 and H2 blockers provides better relief than H1 blockers alone 1
- This is particularly effective for urticaria factitia and certain physical urticarias 6
Corticosteroids for Severe Cases
- Use oral corticosteroids for severe or generalized hives covering >30% body surface area or when antihistamines fail 1, 2
- Prednisone 40-60 mg daily (or 0.5-1 mg/kg/day) until hives resolve to grade 1 or less 1, 2, 5
- Alternative: prednisolone 50 mg daily for 3 days 2
- Limit corticosteroids to short courses only—never use long-term for chronic urticaria except in very selected cases under specialist supervision 2, 5
- Lower steroid doses are frequently effective and should be considered to minimize exposure 2
Critical Pitfalls to Avoid
- Do not delay epinephrine if any signs of anaphylaxis develop (breathing difficulty, widespread worsening, facial/throat swelling, wheezing) 1, 5
- Hives can be the first symptom of developing anaphylaxis, which progresses rapidly 1
- Epinephrine is first-line for systemic hives with organ involvement, not antihistamines 1, 2, 5
- Avoid first-generation sedating antihistamines (diphenhydramine, hydroxyzine) as first-line therapy due to significant sedation, cognitive impairment, and potential to convert minor reactions into hemodynamically significant events without superior efficacy 2, 5, 7
- Never use chronic corticosteroids for chronic spontaneous urticaria—this is the most critical error 2
When to Escalate Care
Prescribe an epinephrine auto-injector if moderate-to-severe urticaria occurred, indicating higher risk for future severe reactions 1
Refer to allergist for trigger identification and prevention strategies, especially if symptoms persist beyond 3-5 days or recur 1
Patient Education and Monitoring
- Warn about potential recurrence over the next 1-2 days even after stopping the trigger—this is expected and does not indicate treatment failure 1
- Provide emergency instructions: seek immediate care if breathing difficulty, widespread worsening urticaria, or facial/throat swelling develops 1
- Schedule follow-up in 3-5 days to ensure complete resolution 1
- Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 3, 5
Special Considerations for Chronic Urticaria (>6 weeks)
- If urticaria becomes chronic and unresponsive to high-dose antihistamines, escalate to omalizumab 300 mg every 4 weeks rather than chronic corticosteroids 2, 5
- Allow up to 6 months for response to omalizumab before considering alternatives 5
- Alternatively, cyclosporine 4 mg/kg daily for up to 2 months is effective in two-thirds of severe autoimmune urticaria cases unresponsive to antihistamines 2, 5