What is the recommended treatment for a patient presenting with urticaria?

Urticaria Treatment

Start with a standard dose of a second-generation H1 antihistamine (cetirizine, loratadine, fexofenadine, desloratadine, or levocetirizine) taken daily, and if symptoms persist after 2-4 weeks, increase the dose up to 4 times the standard dose before considering additional therapies. 1, 2, 3

First-Line Treatment Approach

Second-generation H1 antihistamines are the cornerstone of urticaria management and must be taken daily, not as needed. 1, 2

• Offer patients a choice of at least two different non-sedating antihistamines, as individual responses vary significantly between patients 1, 2
• Second-generation agents are strongly preferred over first-generation antihistamines due to superior safety profiles and reduced sedation 1
• Approximately 40% of patients respond well to standard-dose antihistamines alone 3

Dose Escalation Strategy (Step 2)

If inadequate symptom control after 2-4 weeks on standard dosing:

• Increase the second-generation H1 antihistamine dose up to 4 times the standard dose 1, 2, 3
• This approach exceeds manufacturer's licensed recommendations but is supported by guidelines when potential benefits outweigh risks 2
• Approximately 50% of patients require this dose escalation to achieve adequate control 2
• Younger children (ages 2-6 years) are more likely to need higher doses 2

Adjunctive Therapies for Resistant Cases

When high-dose second-generation antihistamines provide insufficient control:

• Add montelukast as adjunctive therapy, particularly beneficial in aspirin-sensitive or autoimmune urticaria 2
• Consider adding H2 antihistamines (famotidine) for additional benefit 2
• First-generation antihistamines (hydroxyzine, chlorpheniramine) may be added at bedtime for additional symptom control and sleep assistance, but avoid as first-line monotherapy 2

Critical Caveat on Corticosteroids

• Restrict oral corticosteroids to short courses only (3-10 days) for severe acute exacerbations or angioedema affecting the mouth 2
• Avoid long-term corticosteroid use in chronic urticaria except in very selected cases under specialist supervision 2
• Do not use prolonged corticosteroids while trialing other adjunctive therapies 2

Second-Line Treatment for Refractory Disease

For patients failing high-dose antihistamines with or without adjunctive therapy:

• Omalizumab 300 mg subcutaneously every 4 weeks is the recommended second-line therapy 2, 3
• Allow up to 6 months for response before considering alternatives 2
• Do not delay omalizumab in patients with severe, refractory disease who clearly meet criteria for second-line therapy 2
• Cyclosporine is an alternative for omalizumab non-responders 1, 4

General Management Measures

Identify and avoid aggravating factors:

• NSAIDs, aspirin, codeine (can worsen urticaria) 1, 3
• Alcohol, overheating, and stress 1, 3
• ACE inhibitors must be avoided in patients with angioedema without wheals and used cautiously when angioedema accompanies urticaria 3

Symptomatic relief measures:

• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) 1, 2

Stepping Down Treatment

Once complete symptom control is achieved:

• Do not step down therapy before completing at least 3 consecutive months of complete control 1, 2
• Reduce the daily dose gradually by no more than 1 tablet per month 1, 2
• If symptoms recur during step-down, return to the last dose that provided complete control 1, 2
• Use an "as much as needed and as little as possible" approach 2

Monitoring Disease Activity

• Use validated patient-reported outcome measures to guide treatment decisions 3
• The Urticaria Control Test (UCT) cutoff for well-controlled disease is ≥12 points 3
• The Angioedema Control Test (AECT) cutoff for well-controlled disease is ≥10 points 3
• Regularly assess disease activity, quality of life impact, and treatment response 1

Emergency Management

For anaphylaxis or severe laryngeal angioedema:

• Administer intramuscular epinephrine immediately (150 µg for children 15-30 kg, 300 µg for those over 30 kg) 2
• Follow with antihistamines and corticosteroids as needed 2

Important Diagnostic Considerations

• Wheals lasting >24 hours suggest possible urticarial vasculitis requiring skin biopsy, not ordinary urticaria 3
• Physical urticaria weals typically resolve within 1 hour, except delayed pressure urticaria which can last up to 48 hours 1
• No routine extensive laboratory testing is needed unless history suggests specific underlying causes 3

Prognosis

• Approximately 50% of patients with wheals alone will be clear by 6 months 2, 3
• Patients with both wheals and angioedema have a poorer outlook, with >50% still having active disease after 5 years 3
• More than half of patients with chronic urticaria will have resolution or improvement within one year 4