Urticaria Treatment & Management

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

Prehospital Care

  • Timely transport to the ED for any patient with signs or symptoms of an 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 of time, although it usually presents as rapid-onset shock with no urticaria or angioedema.[22] . 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[23] if they are available.
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Emergency Department Care

The management of urticaria is straightforward and typically is not altered by underlying etiology. The mainstay is avoidance of further exposure to the antigen.

  • Antihistamines, primarily the older sedating antihistamines that block the H1 receptors, are the first line of therapy for urticaria.[23]
    • Diphenhydramine and hydroxyzine are the most commonly used H1-blocking antihistamine. They act more rapidly than the minimally sedating H1-blocking antihistamines. These medications are potentially sedating, and the patient should not be allowed to drive within 6 hours of their administration.
    • H1-blocking antihistamines are effective in relieving the pruritus and rash of acute urticaria in most cases. Their effects are dose related, but higher doses may cause excessive sedation as well as serious anticholinergic side effects.[24]
  • Newer H1-blocking minimally sedating antihistamines are now available and include fexofenadine, loratadine, desloratadine, cetirizine, and levocetirizine. These are used primarily in the management of chronic urticaria rather than acute urticaria. However, if acute urticaria persists for more than 24-48 hours, the minimally sedating antihistamines should be prescribed, with supplementation with the sedating antihistamines if the pruritus and urticaria are refractory to the longer-acting, minimally sedating antihistamines.[3]
  • H2 antihistamines, such as cimetidine, famotidine, and ranitidine, have a role when used in combination with H1 antihistamines in urticaria. H1 and H2 antihistamines are thought to have a synergistic effect and often result in a more rapid and complete resolution of urticaria than H1 antihistamines alone, especially if given simultaneously intravenously.[25] Oral H2 antihistamines may occasionally be effective in patients with both acute and chronic urticaria refractory to H1 blockers alone.[26]
  • 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.[27]
  • Glucocorticoids stabilize mast cell membranes and inhibit further histamine release. They also reduce the inflammatory effect of histamine and other mediators.
    • The efficacy of glucocorticoids in acute urticaria remains controversial. In one study, acute urticaria improved more quickly in the group treated with prednisone than in the group treated with placebo.[28]
    • 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.[3]
  • The efficacy of epinephrine in acute urticaria is controversial.[23] If angioedema is present with urticaria, 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.[29]
  • The use of methotrexate, colchicine, dapsone, indomethacin, and hydroxychloroquine may be effective in the management of vasculitic urticaria.[4]
  • Patients with chronic or recurrent urticaria should be referred to a dermatologist for further evaluation and management.
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Consultations

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 vasculitic urticaria is suspected.

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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.

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