Urticaria Medication

  • Author: M Scott Linscott, MD, FACEP; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Apr 2, 2010
 

Medication Summary

Most cases of simple acute urticaria can be treated with H1 antihistamine agents.[30] In cases of severe or persistent urticaria, H2 antihistamines may be added and are probably additive to the effect of H1 antihistamines if given simultaneously intravenously.[25] This combination may also be effective orally in a small percentage of patients with chronic urticaria.[23] If the patient with chronic urticaria is refractory to nonsedating antihistamines, doses up to 4 times the recommended maximal dose may be effective.[23] If maximum doses of nonsedating antihistamines are not effective, other therapies should be tried.[31, 32]

Refractory cases of chronic urticaria may improve with glucocorticosteroids. Chronic urticaria may benefit from doxepin, a tricyclic antidepressant with potent antihistamine properties. Because of its significant sedative properties, it should be given at bedtime. Topical therapy with 5% doxepin cream (Zonalon) or capsaicin may also be used in refractory cases. Cyproheptadine may be useful to suppress recurrent cold urticaria. One study showed that the combination of a leukotriene receptor antagonist and a nonsedating antihistamine was superior to the antihistamine alone in treating chronic idiopathic urticaria.[33] Cyclosporine and omalizumab have been shown to be effective in cases of refractory chronic urticaria.[34, 6, 35]

Next

H1-receptor antagonist antihistamines

Class Summary

These agents block the histamine response in sensory nerve endings and blood vessels. They act by competitive inhibition of histamine at the H1 receptor, which mediates wheal and flare reactions, bronchial constriction, mucus secretion, smooth muscle contraction, and edema. Because they have significant anticholinergic activity, especially the older sedating antihistamines, they may cause hypotension, CNS depression, urinary retention, and cardiac arrhythmias, especially in higher therapeutic doses or overdoses.

View full drug information

Hydroxyzine hydrochloride (Atarax, Vistaril)

 

Sedating peripheral H1 receptor antagonist. Very effective in urticaria. Also may suppress histamine activity in subcortical region of CNS.

View full drug information

Diphenhydramine (Benadryl, Benylin, Diphen)

 

Sedating peripheral H1 receptor antagonist. Used for symptomatic relief of allergic symptoms caused by histamine released in response to allergens.

View full drug information

Cyproheptadine (Periactin)

 

Sedating H1 antihistamine for symptomatic relief of allergic symptoms caused by histamine released in response to allergens and skin manifestations.

View full drug information

Cetirizine (Zyrtec)

 

Selectively inhibits peripheral histamine H1-receptors. Minimally sedating.

View full drug information

Levocetirizine (Xyzal)

 

Histamine1-receptor antagonist. Active enantiomer of cetirizine. Peak plasma levels reached within 1 h and half-life is about 8 h. Available as a 5-mg breakable (scored) tab. Indicated for seasonal and perennial allergic rhinitis.

View full drug information

Fexofenadine (Allegra)

 

Selectively inhibits peripheral histamine H1-receptors. Minimally sedating.

View full drug information

Loratadine (Claritin, Alavert)

 

Selectively inhibits peripheral histamine H1-receptors. Minimally sedating.

View full drug information

Desloratadine (Clarinex)

 

Long-acting tricyclic histamine antagonist selective for H1-receptor. Major metabolite of loratadine, which after ingestion is extensively metabolized to active metabolite 3-hydroxydesloratadine.

Previous
Next

Tricyclic antidepressants (TCAs)

Class Summary

These agents are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. Some TCAs (eg, doxepin) have antihistamine effects, blocking both the H1 and H2 receptors and have been used in the treatment of allergic reactions, especially urticaria.

View full drug information

Doxepin (Sinequan, Adapin, Zonalon)

 

Inhibits histamine and acetylcholine activity and has proven useful in treatment of allergic dermatologic disorders.

Previous
Next

Glucocorticoids

Class Summary

These agents decrease the inflammation associated with urticaria resistant to H1- and H2-receptor antihistamine therapy. They do not inhibit mast cell degranulation and are of limited efficacy in acute urticaria. They are often effective in chronic urticaria but should be tapered to the lowest effective dose to prevent long-term complications.

View full drug information

Prednisone (Deltasone, Orasone, Meticorten)

 

Used in treatment of various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Previous
Next

H2-receptor antagonists

Class Summary

These are reversible, competitive blockers of histamine at H2 receptors, particularly those in gastric parietal cells. The H2 antagonists are highly selective, do not affect H1 receptors, and are not anticholinergic agents. They block the vasodilation mediated by the H2 receptors in blood vessels, possibly leading to less edema formation in urticaria.

The combination of H1 and H2 antagonists may be useful in acute urticaria as well as chronic idiopathic urticaria not responding to H1 antagonists alone. This combination in IV form also may be useful for itching and flushing in anaphylaxis, pruritus, urticaria, and contact dermatitis.

View full drug information

Famotidine (Pepcid)

 

H2 antagonist that, when combined with an H1 type, may be useful in treating allergic reactions that do not respond to H1 antagonists alone.

View full drug information

Ranitidine (Zantac)

 

H2 antagonist that, when combined with an H1 type, may be useful in treating allergic reactions that do not respond to H1 antagonists alone.

View full drug information

Cimetidine (Tagamet)

 

H2 antagonist that, when combined with an H1 type, may be useful in treating allergic reactions that do not respond to H1 antagonists alone.

Previous
Proceed to Follow-up
 
 
Contributor Information and Disclosures
Author

M Scott Linscott, MD, FACEP  Professor, Division of Emergency Medicine, Professor of Surgery (Clinical), University of Utah School of Medicine

M Scott Linscott, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Utah Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven A Conrad, MD, PhD  Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Najib U, Sheikh J. An update on acute and chronic urticaria for the primary care provider. Postgrad Med. Jan 2009;121(1):141-51. [Medline].

  2. Poonawalla T, Kelly B. Urticaria : a review. Am J Clin Dermatol. 2009;10(1):9-21. [Medline].

  3. Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol. 2009;10(4):239-50. [Medline].

  4. Brown NA, Carter JD. Urticarial vasculitis. Curr Rheumatol Rep. Aug 2007;9(4):312-9. [Medline].

  5. Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007;87(3):196-205. [Medline].

  6. Kaplan AP, Joseph K, Maykut RJ, Geba GP, Zeldin RK. Treatment of chronic autoimmune urticaria with omalizumab. J Allergy Clin Immunol. Sep 2008;122(3):569-73. [Medline].

  7. Viola M, Quaratino D, Gaeta F, Rumi G, Caruso C, Romano A. Cross-reactive reactions to nonsteroidal anti-inflammatory drugs. Curr Pharm Des. 2008;14(27):2826-32. [Medline].

  8. [Guideline] Magerl M, Borzova E, Gimrnez-Arnau A, Grattan CE, Lawlor F, Mathelier-Fusade P, et al. The definition and diagnostic testing of physical and cholinergic urticarias--EAACI/GA2LEN/EDF/UNEV consensus panel recommendations. Allergy. Dec 2009;64(12):1715-21. [Medline].

  9. Tong LJ, Balakrishnan G, Kochan JP, Kinét JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. Apr 1997;99(4):461-5. [Medline].

  10. Konstantinou GN, Asero R, Maurer M, Sabroe RA, Schmid-Grendelmeier P, Grattan CE. EAACI/GA(2)LEN task force consensus report: the autologous serum skin test in urticaria. Allergy. Sep 2009;64(9):1256-68. [Medline].

  11. Philpott H, Kette F, Hissaria P, Gillis D, Smith W. Chronic urticaria: the autoimmune paradigm. Intern Med J. Nov 2008;38(11):852-7. [Medline].

  12. Hossler EW. Caterpillars and moths: Part I. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol. Jan 2010;62(1):1-10; quiz 11-2. [Medline].

  13. Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. Jun 2009;39(6):777-87. [Medline].

  14. Vonakis BM, Saini SS. New concepts in chronic urticaria. Curr Opin Immunol. Dec 2008;20(6):709-16. [Medline].

  15. Guldbakke KK, Khachemoune A. Etiology, classification, and treatment of urticaria. Cutis. Jan 2007;79(1):41-9. [Medline].

  16. Bains SN, Hsieh FH. Current approaches to the diagnosis and treatment of systemic mastocytosis. Ann Allergy Asthma Immunol. Jan 2010;104(1):1-10; quiz 10-2, 41. [Medline].

  17. Goldfinger S. The inherited autoinflammatory syndrome: a decade of discovery. Trans Am Clin Climatol Assoc. 2009;120:413-8. [Medline].

  18. Nichols KM, Cook-Bolden FE. Allergic skin disease: major highlights and recent advances. Med Clin North Am. Nov 2009;93(6):1211-24. [Medline].

  19. Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. Mar 2008;100(3):181-8; quiz 188-90, 215. [Medline].

  20. Botto NC, Warshaw EM. Solar urticaria. J Am Acad Dermatol. Dec 2008;59(6):909-20; quiz 921-2. [Medline].

  21. Irinyi B, Szeles G, Gyimesi E, Tumpek J, Heredi E, Dimitrios G, et al. Clinical and laboratory examinations in the subgroups of chronic urticaria. Int Arch Allergy Immunol. 2007;144(3):217-25. [Medline].

  22. Simons FE. Anaphylaxis. J Allergy Clin Immunol. Feb 2010;125(2 Suppl 2):S161-81. [Medline].

  23. [Guideline] Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau AM, et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. Oct 2009;64(10):1427-43. [Medline].

  24. Sype JW, Khan IA. Prolonged QT interval with markedly abnormal ventricular repolarization in diphenhydramine overdose. Int J Cardiol. Mar 18 2005;99(2):333-5. [Medline].

  25. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. Nov 2000;36(5):462-8. [Medline].

  26. Jauregui I, Ferrer M, Montoro J, Davila I, Bartra J, del Cuvillo A, et al. Antihistamines in the treatment of chronic urticaria. J Investig Allergol Clin Immunol. 2007;17 Suppl 2:41-52. [Medline].

  27. Smith PF, Corelli RL. Doxepin in the management of pruritus associated with allergic cutaneous reactions. Ann Pharmacother. May 1997;31(5):633-5. [Medline].

  28. Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med. Nov 1995;26(5):547-51. [Medline].

  29. Bluestein HM, Hoover TA, Banerji AS, Camargo CA Jr, Reshef A, Herscu P. Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emergency department. Ann Allergy Asthma Immunol. Dec 2009;103(6):502-7. [Medline].

  30. Simons FE. H1-Antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol. Oct 2003;112(4 Suppl):S42-52. [Medline].

  31. Balaraman B, Bergstrom KG. Beyond antihistamines: treating chronic urticaria. J Drugs Dermatol. Nov 2009;8(11):1043-8. [Medline].

  32. Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2009. J Allergy Clin Immunol. Jan 2010;125(1):85-97. [Medline].

  33. [Best Evidence] Wan KS. Efficacy of leukotriene receptor antagonist with an anti-H1 receptor antagonist for treatment of chronic idiopathic urticaria. J Dermatolog Treat. 2009;20(4):194-7. [Medline].

  34. Serhat Inaloz H, Ozturk S, Akcali C, Kirtak N, Tarakcioglu M. Low-dose and short-term cyclosporine treatment in patients with chronic idiopathic urticaria: a clinical and immunological evaluation. J Dermatol. May 2008;35(5):276-82. [Medline].

  35. Kessel A, Toubi E. Low-dose cyclosporine is a good option for severe chronic urticaria. J Allergy Clin Immunol. Apr 2009;123(4):970; author reply 970-1. [Medline].

  36. Bailey E, Shaker M. An update on childhood urticaria and angioedema. Curr Opin Pediatr. Aug 2008;20(4):425-30. [Medline].

 
Previous
Next
 
Urticaria developed after bites from an imported fire ant.
Urticaria associated with a drug reaction.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.