From the Guidelines
Treatment for hives should begin with antihistamines, with the option to step up to higher doses or add other medications like omalizumab or cyclosporine as needed, based on the latest guidelines from 2022 1. The goal of treatment is to alleviate symptoms, prevent complications, and improve quality of life. For mild cases, over-the-counter antihistamines like cetirizine (Zyrtec) 10mg daily, loratadine (Claritin) 10mg daily, or diphenhydramine (Benadryl) 25-50mg every 4-6 hours can provide relief, as supported by earlier guidelines 1. Some key points to consider in the management of hives include:
- Identifying and avoiding triggers is crucial for long-term management
- Applying cool compresses to affected areas can help soothe the skin
- Wearing loose-fitting clothing prevents further irritation
- For severe cases that don't respond to antihistamines, corticosteroids like prednisone (typically 40-60mg daily for 3-5 days) might be prescribed for short-term use, as recommended by guidelines from 2007 1
- In chronic cases lasting more than six weeks, medications like omalizumab (Xolair) or cyclosporine may be considered, with the latest guidelines suggesting an "as much as needed and as little as possible" approach 1
- Severe hives accompanied by breathing difficulties, swelling of the face or throat require immediate emergency care as these could indicate anaphylaxis, a life-threatening allergic reaction. It's also important to note that the treatment approach should be individualized, taking into account the patient's response to treatment, potential side effects, and underlying medical conditions, as emphasized by the latest guidelines 1.
From the Research
Treatment Options for Hives
- Antihistamines are the mainstay of treatment for urticaria, with newer nonsedating antihistamines causing significantly less sedation and psychomotor impairment than older counterparts 2
- Loratadine or cetirizine, and possibly mizolastine, appear to be treatments of choice for chronic idiopathic urticaria 2
- For symptomatic dermatographism, the combination of an antihistamine and an H2 antagonist, e.g. chlorpheniramine and cimetidine, appears to be effective 2
- However, hypersensitivity to antihistamines can occur, with reactions ranging from urticaria/angioedema to anaphylaxis, and diagnosis is based on clinical suspicion and may be verified by challenge testing 3
Corticosteroids as a Treatment Option
- A short course of oral prednisone can be effective in treating antihistamine-resistant chronic urticaria, with nearly 50% of patients achieving remission after a single course 4
- Topical corticosteroids may reduce wheal size and itch severity in patients with urticaria, with little to no difference in overall adverse events compared to placebo 5
- However, the evidence for the use of topical corticosteroids in treating urticaria is not yet conclusive, and further large, randomized trials are needed to support optimal urticaria management 5
Other Considerations
- Antihistamines have been used historically to treat atopic dermatitis, but the evidence for their use is inconclusive, and more clinical trials are necessary to elucidate their role in treatment 6
- The use of antihistamines in treating other forms of urticaria, such as cold, cholinergic, and pressure urticaria, is not well studied, and further research is needed to determine their effectiveness 2