From the Guidelines
Urticaria generally does not respond well to topical steroids, and oral antihistamines are the first-line treatment. For acute urticaria, oral antihistamines such as cetirizine 10mg daily, loratadine 10mg daily, or fexofenadine 180mg daily are recommended 1. For more severe cases, a short course of oral corticosteroids like prednisone 20-40mg daily for 3-5 days may be needed, as suggested by guidelines for evaluation and management of urticaria in adults and children 1. Topical steroids are ineffective because urticaria involves deep dermal blood vessels and mast cell activation throughout the skin, which topical preparations cannot adequately reach.
The wheals in urticaria result from histamine release causing vasodilation and increased vascular permeability, which is why antihistamines that block this process are effective. For chronic urticaria lasting more than six weeks, second-generation H1 antihistamines may be increased up to four times the standard dose, and additional treatments like omalizumab or cyclosporine might be considered under specialist care. Cool compresses and avoiding triggers like heat, pressure, and certain foods can provide symptomatic relief. It's worth noting that recent guidelines for managing toxicities associated with immune checkpoint inhibitors also recommend oral antihistamines and oral corticosteroids for pruritus, but do not specifically address urticaria 1. However, the most recent and relevant guideline for urticaria management is from 2007, and it does not support the use of topical steroids as a primary treatment 1.
Some studies suggest the use of topical corticosteroids for skin care in certain conditions, such as systemic mastocytosis 1, but this is not directly applicable to urticaria treatment. Another study provides guidelines for the prevention and management of dermatological toxicities related to anticancer agents, which includes the use of topical moderate/high-potency steroids for pruritus, but again, this is not specific to urticaria 1. Therefore, based on the most relevant and recent evidence, oral antihistamines and oral corticosteroids are the preferred treatments for urticaria, rather than topical steroids.
From the Research
Urticaria Response to Topical Steroids
- Urticaria is a cutaneous syndrome characterized by dermal edema and erythema, typically lasting less than 24 hours and usually pruritic 2
- The mainstay of treatment for urticaria is avoidance of triggers and second-generation H1 antihistamines, which can be titrated to greater than standard doses 3
- Topical corticosteroids may be used as an adjunctive treatment for urticaria, with some studies suggesting they may reduce wheal size and itch severity 4
- A systematic review and Bayesian meta-analysis of randomized trials found that topical corticosteroids may reduce wheal size (ratio of means 0.47,95% CI 0.38-0.59; low certainty) and itch severity (mean difference -1.30,95% CI -5.07 to 2.46; very low certainty) compared with placebo 4
- However, the evidence for the effectiveness of topical corticosteroids in reducing itch severity is very uncertain, and further large, randomized trials are needed to support optimal urticaria management 4
- Systemic corticosteroids, on the other hand, have been shown to improve urticaria activity and itch severity, but may also increase adverse events 5
Key Findings
- Topical corticosteroids may reduce wheal size and itch severity in patients with urticaria 4
- The evidence for the effectiveness of topical corticosteroids in reducing itch severity is very uncertain 4
- Systemic corticosteroids may improve urticaria activity and itch severity, but may also increase adverse events 5
- Second-generation H1 antihistamines remain the mainstay of treatment for urticaria, with topical corticosteroids used as an adjunctive treatment 3, 2