What is the recommended treatment for acute urticaria and chronic urticaria?

Treatment for Hives (Urticaria)

Start immediately with a second-generation non-sedating H1 antihistamine (cetirizine, loratadine, desloratadine, fexofenadine, or levocetirizine) as first-line therapy for both acute and chronic urticaria. 1, 2

Acute Urticaria Management

First-Line: Second-Generation Antihistamines

• Begin with standard dosing of a second-generation H1 antihistamine such as cetirizine 10 mg daily or loratadine 10 mg daily 3, 2
• Offer at least two different antihistamine options since individual responses vary significantly between agents 1, 2
• Avoid first-generation antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) as primary therapy due to significant sedation and potential to worsen outcomes 2
• Cetirizine has the shortest time to maximum concentration, making it advantageous when rapid relief is needed 1

Dose Escalation for Inadequate Response

• If standard dosing provides inadequate control within 24-48 hours, increase the antihistamine dose up to 4 times the standard dose 1, 2
• This dose escalation strategy is supported when benefits outweigh risks 2

Add Corticosteroids for Moderate-to-Severe Cases

• For moderate to severe acute urticaria, add a short course of oral prednisolone 50 mg daily for 3 days rather than waiting for antihistamine failure 3, 2
• Restrict corticosteroid use to short 3-10 day courses only due to cumulative dose- and time-dependent toxicity 2, 4
• Corticosteroids should not be used chronically 4

Emergency Situations

• If urticaria presents with signs of anaphylaxis (respiratory distress, hypotension, throat swelling), immediately administer intramuscular epinephrine 0.5 mL of 1:1000 solution (500 µg) into the anterolateral thigh 3, 2
• Follow with antihistamines and corticosteroids as adjunctive therapy 2

Chronic Urticaria Management

First-Line: Standard-Dose Antihistamines

• Start with standard dose of a second-generation H1 antihistamine 1, 2
• Assess response after 2-4 weeks at standard dosing 1, 3
• Continuous daily treatment is superior to on-demand dosing - research shows on-demand antihistamines provide minimal benefit for existing wheals 5

Second-Line: High-Dose Antihistamines

• If inadequate control after 2-4 weeks, increase dose up to 4 times the standard dose 1, 3
• This approach is effective in many patients before requiring additional therapies 6, 4

Third-Line: Omalizumab

• For urticaria unresponsive to high-dose antihistamines, add omalizumab 300 mg subcutaneously every 4 weeks 1, 3, 4
• The dose can be increased up to 600 mg every 2 weeks in patients with insufficient response 1
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 3
• Omalizumab is effective in approximately 70% of antihistamine-refractory patients 4

Fourth-Line: Cyclosporine

• For patients who do not respond to high-dose antihistamines and omalizumab within 6 months, add cyclosporine at 4-5 mg/kg body weight daily 1, 3, 4
• Cyclosporine is effective in approximately 65-70% of patients 1, 4
• Monitor blood pressure and renal function (blood urea nitrogen and creatinine) every 6 weeks due to risks of hypertension and renal failure 3, 4

Adjunctive Measures for All Patients

Trigger Identification and Avoidance

• Identify and eliminate triggering factors including NSAIDs, aspirin, codeine, overheating, stress, and alcohol 1, 3, 2
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1
• Upper respiratory tract infections can trigger acute urticaria 2

Symptomatic Relief

• Apply cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream for symptomatic relief 1, 3, 2

Additional Considerations

• First-generation antihistamines may be added at night for additional symptom control, but their sedating effects should be considered 1
• H2 antihistamines and leukotriene antagonists are no longer recommended as they add little efficacy 4

Important Caveats

• At least 30% of chronic urticaria cases have an autoimmune etiology, but this does not change initial management 6
• Over 50% of patients with chronic urticaria will have resolution or improvement within one year 7
• Chronic urticaria remains idiopathic in 80-90% of cases, so extensive investigation is not warranted unless specific underlying conditions are suggested 6, 7
• Patients with weals and angioedema have a poorer prognosis, with over 50% still having active disease after 5 years 6