Treatment of Urticaria in Children

First-Line Treatment

The British Journal of Dermatology recommends second-generation H1 antihistamines (non-sedating) as the cornerstone of urticaria management in children due to their efficacy in controlling symptoms with minimal side effects 1, 2
Options for first-line treatment include cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine 3
These medications should be offered as the initial treatment for all children with urticaria 2
Increasing the dose of second-generation H1 antihistamines above the manufacturer's licensed recommendation may be considered when benefits outweigh risks for children who don't respond adequately to standard doses 1, 2

Combination therapy with H1 and H2 antihistamines (such as ranitidine or famotidine) can be effective for controlling severe pruritus and wheal formation in cases resistant to standard doses of second-generation antihistamines 2, 3
Addition of a sedating antihistamine (such as diphenhydramine or hydroxyzine) at night can help with sleep disruption from pruritus in children with urticaria 2, 3
Leukotriene receptor antagonists (e.g., montelukast) may be added as adjunctive therapy for resistant cases of urticaria in children 2

Identifying and avoiding triggering factors when possible is crucial in managing urticaria in children, with common triggers including hot temperatures, tight clothing, stress/anxiety, and certain medications (especially NSAIDs and aspirin) 1, 4
Cooling antipruritic lotions, such as calamine or 1% menthol in aqueous cream, can provide symptomatic relief for children with urticaria 3
For urticaria associated with mastocytosis, temperature control is particularly important as mast cells can be activated by hot and cold temperatures 5

Ordinary urticaria wheals typically last 2-24 hours, while physical urticaria wheals usually resolve within an hour (except delayed pressure urticaria) 1, 4
Wheals lasting longer than 24 hours may suggest urticarial vasculitis and warrant skin biopsy 1, 2
Most cases of acute urticaria resolve within 6 months, but those with both wheals and angioedema may have a more prolonged course 2

Immunomodulating therapies should be restricted to patients with disabling disease who have not responded to conventional treatments 2

First-generation H1 antihistamines should be avoided as first-line therapy due to their sedative effects, which can impact school performance and cognitive function in children with urticaria 3
NSAIDs should be avoided in aspirin-sensitive patients with urticaria due to risk of cross-reactions 3