Urticaria Management and Treatment

Clinical Classification and Evaluation

The British Journal of Dermatology recommends that urticaria can usually be classified based on clinical presentation without extensive investigation 2
Physical urticaria is characterized by weals that typically last less than 1 hour (except delayed pressure urticaria), according to the British Journal of Dermatology 2
Ordinary urticaria is defined by weals that typically last 2-24 hours, as stated by the British Journal of Dermatology 2
Urticarial vasculitis should be suspected if weals last longer than 24 hours, and can be confirmed with skin biopsy, as recommended by the British Journal of Dermatology 2
The Journal of Allergy and Clinical Immunology suggests assessing the severity of urticaria using a standardized approach, with mild being less than 3 hives, moderate being 3-10 hives, and severe being generalized involvement 3
The Pediatrics journal recommends checking for signs of anaphylaxis, including respiratory symptoms, hypotension, or gastrointestinal symptoms 4

The British Journal of Dermatology recommends non-sedating H1 antihistamines as the mainstay of therapy, with options including cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine 1
The British Journal of Dermatology suggests offering patients a choice of at least two non-sedating H1 antihistamines, as responses vary between individuals 1
For inadequate response, the British Journal of Dermatology recommends increasing the dose of non-sedating H1 antihistamines above the licensed recommendation when benefits outweigh risks 1
The British Journal of Dermatology suggests adding a sedating antihistamine at night, such as chlorphenamine or hydroxyzine, to help with sleep disruption 1
For severe or refractory cases, the British Journal of Dermatology recommends short courses of oral corticosteroids, such as prednisolone, and antileukotrienes, such as montelukast 5

The British Journal of Dermatology recommends prompt treatment for angioedema that affects the mouth or airway, including intramuscular epinephrine 5
The Pediatrics journal suggests providing an emergency treatment plan for patients at risk of severe reactions, and considering self-injectable epinephrine prescription for patients with a history of severe reactions 4
The Journal of Allergy and Clinical Immunology recommends advising patients about possible recurrent urticaria over 1-2 days after acute episodes, and scheduling follow-up visits to assess treatment response for chronic urticaria 3

The British Journal of Dermatology states that approximately 50% of patients with chronic urticaria clear within 6 months, while patients with both weals and angioedema may have a poorer prognosis, with over 50% still having active disease after 5 years 2