How should facial hives that occur with a confirmed or suspected streptococcal infection be managed?

Management of Facial Hives with Streptococcal Infection

Facial hives occurring with streptococcal infection should be treated as two separate conditions: the hives require antihistamine therapy while the strep infection requires appropriate antibiotics, but the hives themselves are almost certainly not an allergic reaction to the strep bacteria or any antibiotics given.

Understanding the Clinical Scenario

The key insight is that acute urticaria (hives) occurring during an infectious illness is typically caused by the viral or bacterial infection itself triggering a non-allergic immune response, not by an IgE-mediated allergic reaction 1, 2. In children with acute urticaria associated with infectious disease, viral respiratory infections are the most common trigger, with enterovirus being significantly associated (p = 0.0054) with acute urticaria development 2.

Critical Distinction: Infection vs. Allergy

• Hives during strep infection are post-infectious urticaria, not a drug allergy 1, 2
• Studies show that when antibiotics were given before hives developed, subsequent rechallenge with the same antibiotic was well-tolerated in all patients 2
• The most common causes of new-onset urticaria in children and adults are post-infection or acute idiopathic urticaria, not IgE-mediated allergy 1

Treatment Algorithm

1. Treat the Streptococcal Infection

For confirmed or suspected streptococcal pharyngitis or skin infection:

• Oral penicillin is the recommended agent when cultures yield streptococci alone 3
• Alternative first-line options include dicloxacillin or cephalexin for 7 days if S. aureus co-infection is suspected 3
• For penicillin-allergic patients (true type 1 hypersensitivity), use clindamycin, doxycycline, or trimethoprim-sulfamethoxazole 3

2. Treat the Urticaria

For the facial hives specifically:

• High-dose nonsedating H1-antihistamines are first-line treatment 1, 4
• Continue antihistamines for several days as lesions typically resolve within 2-3 hours but may recur 5
• Avoid systemic corticosteroids - they provide no benefit for post-infectious urticaria and may cause morbidity 1
• Advise acute avoidance of alcohol and NSAIDs which can worsen urticaria 1

3. What NOT to Do

Common pitfalls to avoid:

• Do not stop the antibiotic - the hives are not an allergic reaction to the medication 2
• Do not prescribe epinephrine auto-injectors - these are not indicated for isolated urticaria without signs of anaphylaxis (hypotension, hypoxia, respiratory compromise) 1, 4
• Do not use systemic steroids - they are ineffective for post-infectious urticaria 1
• Do not label the patient as "antibiotic allergic" - this creates unnecessary future treatment limitations 2

Assessment for Severity

Evaluate for features requiring urgent intervention:

The Dutch antibiotic allergy guideline defines severe reactions as those involving 3:

• Respiratory compromise (dyspnea, wheeze, stridor)
• Hypotension or syncope
• Angioedema affecting the airway
• Mucosal involvement with painful/burning lesions

If only facial hives are present without these features, this is a non-severe reaction requiring only antihistamine therapy 3, 5.

When Angioedema is Present

If facial swelling (angioedema) accompanies the hives 5, 4:

• Most angioedema without itching is idiopathic and self-limited 1
• Treatment is supportive care and time 1
• Antihistamines may provide modest benefit if itching is present 5, 4
• Epinephrine and steroids are ineffective for non-anaphylactic angioedema 1

Follow-Up Considerations

• Symptoms typically resolve within 24-72 hours with treatment 5, 4
• If urticaria persists beyond 6 weeks, it becomes chronic urticaria requiring different evaluation 5, 6
• No allergy testing or antibiotic avoidance is needed for future strep infections 2
• Document clearly that this was post-infectious urticaria, not drug allergy, to prevent inappropriate antibiotic restrictions 1, 2