Urticaria Treatment & Management
- Author: Henry K Wong, MD, PhD; Chief Editor: Dirk M Elston, MD more...
Timely transport to the ED for any patient with signs or symptoms of a life-threatening allergic reaction, including urticaria, angioedema, or anaphylactic shock is essential. Acute urticaria may progress to life-threatening angioedema and/or anaphylactic shock in a very short period, although anaphylaxis usually presents as rapid-onset shock with no urticaria or angioedema. See Anaphylaxis.
If associated angioedema is present, especially if laryngeal angioedema (eg, hoarseness, stridor) is suspected, prehospital administration of 0.3-0.5 mg of intramuscular epinephrine may be warranted.
If associated bronchospasm is present, prehospital nebulized albuterol may be warranted.
Other measures may be appropriate, such as continuous ECG, blood pressure and pulse oximetry monitoring; administering intravenous crystalloids if the patient is hypotensive; and administering oxygen.
Diphenhydramine (25 mg IV or 50 mg IM or PO) or hydroxyzine (50 mg IM or PO) should be administered if they are available.
The management of urticaria is straightforward and typically is not altered by underlying etiology.
Antihistamines are first-line therapy for urticaria. The older sedating antihistamines (first-generation antihistamines) that block the H1 receptors were previously first-line therapy for urticaria.[6, 7] Diphenhydramine and hydroxyzine are the most commonly used in this class. They act more rapidly than the minimally sedating H1-blocking antihistamines and are effective in relieving the pruritus and rash in most cases. However, because these medications are often sedating with the potential for other anticholinergic adverse effects, second-generation antihistamines are now considered first line.[8, 32, 35, 36]
Newer H1-blocking, minimally sedating, second-generation antihistamines are now available and include fexofenadine, loratadine, desloratadine, cetirizine, and levocetirizine. These are now considered first line and are used in the management of both acute and chronic urticaria.[36, 37] If symptoms are uncontrolled, the dose can be increased up to four-fold. In fact, up-dosing has been shown to increase the response rate without increasing the adverse effect profile. If symptoms are still uncontrolled, a first-generation antihistamine can be added.
H2 antihistamines, such as cimetidine, famotidine, and ranitidine, may have a role when used in combination with H1 antihistamines in urticaria. H1 and H2 antihistamines are thought to have a synergistic effect that may result in a more rapid and complete resolution of urticaria than H1 antihistamines alone. Cimetidine, in particular, is thought to effect cytochrome P450 enzymes involved in the metabolism of first-generation antihistamines, thus increasing their plasma concentrations. Because of this, H2 antihistamines are often added in combination with H1 antihistamines in the treatment of acute and chronic urticaria. However, the evidence supporting the use of H2 antihistamines in combination with H1 antihistamines is weak and does not seem to show any advantage over use of H1 antihistamines alone. Thus, their addition is often physician dependent.[23, 32, 36, 39]
Doxepin is an antidepressant and an antihistamine that blocks both H1 and H2 receptors and may be effective in refractory cases of urticaria in doses of 25-50 mg at bedtime or 10-25 mg 3-4 times a day.
Glucocorticoids stabilize mast cell membranes and inhibit further histamine release. They also reduce the inflammatory effect of histamine and other mediators. Oral glucocorticoids are effective in acute urticaria but are not suitable for long-term use. In one study, acute urticaria improved more quickly in the group treated with prednisone than in the group treated with placebo. In adults, 40-60 mg daily of prednisone for 5 days is a reasonable therapeutic regimen. In children, the treatment is 1 mg/kg/d for 5 days. Tapering of the corticosteroid dose is not necessary in most cases of acute urticaria.
If urticaria is present with angioedema and systemic symptoms such as coughing or wheezing are present, raising concern for anaphylaxis, 0.3-0.5 mg of epinephrine should be administered intramuscularly. Remember that ACE-inhibitor–induced angioedema usually does not respond to epinephrine or most other common therapies, since it is not an IgE-mediated process.
The use of methotrexate, colchicine, dapsone, indomethacin, and hydroxychloroquine may be effective in the management of urticarial vasculitis.
Treatment of chronic urticaria is sometimes achieved with omalizumab.
Patients with chronic or recurrent urticaria should be referred to a dermatologist for further evaluation and management.
In general, patients with urticaria can be cared for on an outpatient basis unless their urticaria is severe and does not respond to antihistamine therapy or if they progress to laryngeal angioedema and/or anaphylactic shock, or have comorbidities that require inpatient therapy.
Consultation with or referral to a dermatologist, allergist, immunologist, or rheumatologist may be appropriate in selected cases, particularly in cases of complicated, recurrent, refractory, severe, or chronic urticaria. Dermatology referral is mandatory if urticarial vasculitis is suspected.
Patients with acute urticaria should avoid any medication, food, or other allergen that has precipitated urticaria or other serious allergic reaction previously. Chronic urticaria is seldom related to food allergens, and complicated elimination diets are seldom of benefit.
Most patients with urticaria can be treated at home with first- or second-generation H1 antihistamines alone or in combination with one another (ie, cetirizine uptitrated to 20 mg twice daily, diphenhydramine 50 mg q6h or hydroxyzine 50 mg q6h for 24-48 h) In refractory cases, oral glucocorticoids can be added. Additional therapies likely warrant referral to a specialist.
If the patient has angioedema that is treated successfully in the ED, the patient should be sent home with an EpiPen prescription and told to keep it with him or her at all times and to use it if swelling of the lips, tongue, face develops or if his or her voice acutely become hoarse.
Consultation with or referral to a dermatologist, allergist, immunologist, or rheumatologist may be appropriate in cases of suspected urticarial vasculitis and in cases of chronic or recurrent urticaria.
Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol. 2009. 10(4):239-50. [Medline].
Poonawalla T, Kelly B. Urticaria : a review. Am J Clin Dermatol. 2009. 10(1):9-21. [Medline].
Ribeiro F, Sousa N, Carrapatoso I, Segorbe Luís A. Urticaria after ingestion of alcoholic beverages. J Investig Allergol Clin Immunol. 2014. 24(2):122-3. [Medline].
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].
Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010 Feb. 125(2 Suppl 2):S161-81. [Medline].
[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. 2009 Oct. 64(10):1427-43. [Medline].
Sharma M, Bennett C, Carter B, Cohen SN. H1-antihistamines for chronic spontaneous urticaria: An abridged Cochrane Systematic Review. J Am Acad Dermatol. 2015 Aug 4. [Medline].
Bernstein JA, Lang DM, Khan DA, et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014 May. 133(5):1270-7. [Medline].
Brown NA, Carter JD. Urticarial vasculitis. Curr Rheumatol Rep. 2007 Aug. 9(4):312-9. [Medline].
Najib U, Sheikh J. An update on acute and chronic urticaria for the primary care provider. Postgrad Med. 2009 Jan. 121(1):141-51. [Medline].
Viegas LP, Ferreira MB, Kaplan AP. The maddening itch: an approach to chronic urticaria. J Investig Allergol Clin Immunol. 2014. 24(1):1-5. [Medline].
Darlenski R, Kazandjieva J, Zuberbier T, Tsankov N. Chronic urticaria as a systemic disease. Clin Dermatol. 2014 May-Jun. 32(3):420-3. [Medline].
Bolognia JL, Jorizzo JL, Shaffer JV. Dermatology. 3rd ed. Philadelphia, Pa: Elsevier Saunders; 2012.
Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007. 87(3):196-205. [Medline].
Kaplan AP, Joseph K, Maykut RJ, Geba GP, Zeldin RK. Treatment of chronic autoimmune urticaria with omalizumab. J Allergy Clin Immunol. 2008 Sep. 122(3):569-73. [Medline].
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].
[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. 2009 Dec. 64(12):1715-21. [Medline].
Kasperska-Zajac A, Jasinska T, Grzanka A, Kowalik-Sztylc A. Markers of systemic inflammation in delayed pressure urticaria. Int J Dermatol. 2012 Nov 1. [Medline].
Tong LJ, Balakrishnan G, Kochan JP, Kinét JP, Kaplan AP. Assessment of autoimmunity in patients with chronic urticaria. J Allergy Clin Immunol. 1997 Apr. 99(4):461-5. [Medline].
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. 2009 Sep. 64(9):1256-68. [Medline].
Philpott H, Kette F, Hissaria P, Gillis D, Smith W. Chronic urticaria: the autoimmune paradigm. Intern Med J. 2008 Nov. 38(11):852-7. [Medline].
Konstantinou GN, Asero R, Ferrer M, Knol EF, Maurer M, Raap U, et al. EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria. Allergy. 2012 Nov 15. [Medline].
[Guideline] Powell RJ, Leech SC, Till S, Huber PA, Nasser SM, Clark AT. BSACI guideline for the management of chronic urticaria and angioedema. Clin Exp Allergy. 2015 Mar. 45 (3):547-65. [Medline].
Hossler EW. Caterpillars and moths: Part I. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol. 2010 Jan. 62(1):1-10; quiz 11-2. [Medline].
Kaplan AP, Greaves M. Pathogenesis of chronic urticaria. Clin Exp Allergy. 2009 Jun. 39(6):777-87. [Medline].
Vonakis BM, Saini SS. New concepts in chronic urticaria. Curr Opin Immunol. 2008 Dec. 20(6):709-16. [Medline].
Guldbakke KK, Khachemoune A. Etiology, classification, and treatment of urticaria. Cutis. 2007 Jan. 79(1):41-9. [Medline].
Bains SN, Hsieh FH. Current approaches to the diagnosis and treatment of systemic mastocytosis. Ann Allergy Asthma Immunol. 2010 Jan. 104(1):1-10; quiz 10-2, 41. [Medline].
Nichols KM, Cook-Bolden FE. Allergic skin disease: major highlights and recent advances. Med Clin North Am. 2009 Nov. 93(6):1211-24. [Medline].
Brodell LA, Beck LA. Differential diagnosis of chronic urticaria. Ann Allergy Asthma Immunol. 2008 Mar. 100(3):181-8; quiz 188-90, 215. [Medline].
Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, et al. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J. 2012 Nov. 5 (11):125-47. [Medline].
Botto NC, Warshaw EM. Solar urticaria. J Am Acad Dermatol. 2008 Dec. 59(6):909-20; quiz 921-2. [Medline].
Kaplan AP. Therapy of chronic urticaria: a simple, modern approach. Ann Allergy Asthma Immunol. 2014 May. 112(5):419-425. [Medline].
Sype JW, Khan IA. Prolonged QT interval with markedly abnormal ventricular repolarization in diphenhydramine overdose. Int J Cardiol. 2005 Mar 18. 99(2):333-5. [Medline].
[Guideline] Fine LM, Bernstein JA. Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines. Curr Allergy Asthma Rep. 2015 Jun. 15 (6):30. [Medline].
Sil A, Tripathi SK, Chaudhuri A, Das NK, Hazra A, Bagchi C, et al. Olopatadine versus levocetirizine in chronic urticaria: an observer-blind, randomized, controlled trial of effectiveness and safety. J Dermatolog Treat. 2012 Nov 19. [Medline].
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. 2000 Nov. 36(5):462-8. [Medline].
Fedorowicz Z, van Zuuren EJ, Hu N. Histamine H2-receptor antagonists for urticaria. Cochrane Database Syst Rev. 2012 Mar 14. 3:CD008596. [Medline].
Smith PF, Corelli RL. Doxepin in the management of pruritus associated with allergic cutaneous reactions. Ann Pharmacother. 1997 May. 31(5):633-5. [Medline].
Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med. 1995 Nov. 26(5):547-51. [Medline].
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. 2009 Dec. 103(6):502-7. [Medline].
Rajan JP, Simon RA, Bosso JV. Prevalence of sensitivity to food and drug additives in patients with chronic idiopathic urticaria. J Allergy Clin Immunol Pract. 2014 Mar-Apr. 2(2):168-71. [Medline].
Simons FE. H1-Antihistamines: more relevant than ever in the treatment of allergic disorders. J Allergy Clin Immunol. 2003 Oct. 112(4 Suppl):S42-52. [Medline].
Balaraman B, Bergstrom KG. Beyond antihistamines: treating chronic urticaria. J Drugs Dermatol. 2009 Nov. 8(11):1043-8. [Medline].
Sicherer SH, Leung DY. Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2009. J Allergy Clin Immunol. 2010 Jan. 125(1):85-97. [Medline].
Okubo Y, Shigoka Y, Yamazaki M, Tsuboi R. Double dose of cetirizine hydrochloride is effective for patients with urticaria resistant: a prospective, randomized, non-blinded, comparative clinical study and assessment of quality of life. J Dermatolog Treat. 2013 Apr. 24(2):153-60. [Medline].
Maurer M, Rosén K, Hsieh HJ, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013 Mar 7. 368(10):924-35. [Medline].
Kai AC, Flohr C, Grattan CE. Improvement in quality of life impairment followed by relapse with 6-monthly periodic administration of omalizumab for severe treatment-refractory chronic urticaria and urticarial vasculitis. Clin Exp Dermatol. 2014 Apr 23. [Medline].
Lang DM. Omalizumab is efficacious for management of recalcitrant, antihistamine-resistant chronic urticaria. Drugs Today (Barc). 2015 Jun. 51 (6):367-74. [Medline].
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].
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. 2008 May. 35(5):276-82. [Medline].
Kessel A, Toubi E. Low-dose cyclosporine is a good option for severe chronic urticaria. J Allergy Clin Immunol. 2009 Apr. 123(4):970; author reply 970-1. [Medline].