What topical anti‑itch medication is first‑line for acute urticaria (hives)?

Topical Anti-Itch Treatment for Acute Urticaria (Hives)

Topical corticosteroids are the first-line topical anti-itch medication for acute urticaria, specifically medium- to high-potency formulations like clobetasol propionate or betamethasone dipropionate for the body, and low-potency hydrocortisone 2.5% for facial areas. 1, 2

Primary Topical Approach

• Apply Class I topical corticosteroids (clobetasol propionate, halobetasol propionate, or betamethasone dipropionate cream/ointment) to affected body areas for rapid itch relief 1, 2

• Use Class V/VI corticosteroids (hydrocortisone 2.5%, desonide, or aclometasone) on facial skin to avoid skin atrophy and telangiectasia 1, 2

• Combine with fragrance-free emollients in cream or ointment base to prevent skin drying and enhance barrier function 2

• Recent meta-analysis evidence shows topical corticosteroids may reduce wheal size (ratio of means 0.47) with little to no difference in adverse events compared to placebo 3

Essential Adjunctive Oral Therapy

Topical corticosteroids alone are insufficient—they must be combined with oral antihistamines for effective urticaria management:

• Start oral non-sedating H1-antihistamines such as cetirizine 10 mg daily or loratadine 10 mg daily, taken regularly on a scheduled basis (not as-needed) 1, 2

• Add sedating antihistamines at bedtime (hydroxyzine 10-25 mg) for nighttime pruritus relief and to break the itch-scratch cycle 1, 2

• Antihistamines provide symptomatic relief and are the cornerstone of urticaria treatment, with topical steroids serving as adjunctive therapy 1

Important Clinical Caveats

Avoid topical antihistamines—they increase the risk of contact dermatitis and lack evidence for efficacy in urticaria 1

Avoid alcohol-containing lotions or gels, which can exacerbate symptoms 2

Do not use topical corticosteroids as monotherapy—they work best when combined with oral antihistamines for comprehensive symptom control 1, 2

When to Escalate Beyond Topical Treatment

• If the rash covers >30% body surface area or causes significant functional impairment, add oral corticosteroids (prednisone 0.5-1 mg/kg/day) 2

• However, recent high-quality evidence shows adding systemic corticosteroids to antihistamines does not improve outcomes in acute urticaria and may prolong urticaria activity 4, 5

• Consider dermatology referral if no improvement after 2 weeks of appropriate topical and oral antihistamine therapy 2