Urticaria Management Guidelines

Introduction to Urticaria Treatment

The American Academy of Allergy, Asthma, and Immunology recommends that hydrocortisone is not used as a first-line treatment for urticaria; instead, second-generation antihistamines are the standard treatment, and systemic corticosteroids should only be used for short courses (3 days) for acute severe urticaria that does not respond to antihistamines, never for chronic urticaria 1, 2, 3

The American College of Allergy, Asthma, and Immunology suggests initiating treatment with second-generation H1 antihistamines (cetirizine, loratadine, desloratadina, fexofenadine, levocetirizina) at standard doses for 2-4 weeks 4, 1, 3
Cetirizine is preferred due to its shorter time to maximum concentration, advantageous for rapid relief of symptoms 1
If the response is inadequate after 2-4 weeks, the dose of the antihistamine should be increased up to 4 times the standard dose 4, 1, 2, 3

The American Academy of Allergy, Asthma, and Immunology recommends prednisolone 50 mg daily for 3 days as the regimen for acute urticaria in adults who do not respond adequately to antihistamines 1, 2
Short courses of 3-10 days are appropriate for acute severe exacerbations 2
Lower doses are frequently effective and should be considered to minimize exposure to corticosteroids 2

The American Society of Hematology suggests hydrocortisone 200 mg IV may be used for urticaria occurring during infusion reactions (e.g., intravenous iron) 5, 6
For mild to moderate reactions, consider hydrocortisone 100-500 mg IV if symptoms do not improve after 15 minutes 6
Second-generation antihistamines (loratadine 10 mg PO or cetirizine 10 mg IV/PO) are the preferred treatment for urticaria in this context 5, 6

The British Society for Allergy and Clinical Immunology states that oral corticosteroids should not be used long-term in chronic urticaria except in very selected cases under regular specialized supervision (Recommendation of strength A) 7, 2
This is a firm contraindication due to cumulative toxicity and unfavorable risk-benefit ratio 2
Limit corticosteroid courses to a maximum of 3-4 weeks 1

Add H2 antihistamines (ranitidine or famotidine) for resistant cases 1, 3
Consider leukotriene receptor antagonists (montelukast), particularly beneficial for aspirin-sensitive and autoimmune urticaria 1, 3

Omalizumab 300 mg subcutaneously every 4 weeks for severe chronic urticaria resistant to antihistamines 1, 3
Cyclosporine 4 mg/kg daily is effective in approximately two-thirds of patients with severe autoimmune urticaria 1, 2, 3

The most critical error is using chronic corticosteroids for chronic spontaneous urticaria 2
Avoid aspirin and NSAIDs in patients with urticaria, as they inhibit cyclooxygenase and can exacerbate symptoms 1
Avoid first-generation antihistamines (diphenhydramine) in infusion reactions, as they can convert minor reactions into hemodynamically significant adverse events 5, 6
Do not use hydrocortisone as routine treatment when antihistamines are sufficient 1, 2

Administer epinephrine intramuscularly immediately for anaphylaxis or severe laryngeal angioedema 1
Adult/adolescent dose: 0.5 mL of 1:1000 (500 µg) epinephrine intramuscularly 1

Minimize nonspecific aggravating factors, including overheating, stress, and alcohol 1, 3
Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 1, 3