eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Urticaria: Treatment & Medication

Author: Shih-Wen Huang, MD, Medical Director of Allergy Service, Professor, Department of Pediatrics, Division of Immunology and Infectious Diseases, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Jun 15, 2009

Treatment

Medical Care

  • Allergen avoidance is an important strategy to prevent urticaria if the allergen can be identified.
  • Because drug-induced urticaria accounts for most acute urticaria in children, drug use should be specifically reviewed in the history. Certain classes of drugs may release histamine directory from mast cells without any allergic interaction (eg, opiates, acetylsalicylic acid).
  • Removing offending ectoparasites can prevent papular urticaria.
  • If the allergen cannot be identified or avoided, most cases of urticaria respond to medications (see Medication).

Consultations

  • A study recently indicated that patients with chronic urticaria have psychological distress.10 The serum level of dehydroepiandrosterone sulfate declined in many of the patients, indicating the phenomenon was secondary to psychological disturbance. Thus, psychological consultation may be indicated in some of patients.

Diet

  • If urticaria is caused by ingestion of a particular food, avoidance can prevent future reactions.

Activity

  • If the patient has physical urticaria, activity should be carefully monitored, depending on the trigger (eg, cold or hot temperatures, exposure to sun or water, pressure or vibration).
  • Individuals with cold urticaria must be particularly cautious and not immerse themselves suddenly in cold water. Patients should avoid swimming in lakes, streams, or oceans.

Medication

Urticaria can be controlled by use of medications that alter the effects of mediators that have been released by the mast cells. Antihistamines are the mainstay of therapy; more recently, leukotriene antagonists have been successfully used. Clinical trials are in progress to determine whether antileukotriene medications can provide a synergistic response with antihistamines. Patients in whom urticaria is a precursor to anaphylaxis should carry epinephrine whenever they are at risk.

Mediator release can be affected by anti-inflammatory therapy, specifically corticosteroids. Although antihistamines are the mainstay of therapy, a short course of systemic corticosteroids can be very effective in establishing control while the etiology is being investigated. However, long-term therapy should be avoided because of the systemic side effects. Other immunomodulating therapies have been used in cases of urticaria suspected to have an autoimmune process. These therapies include intravenous gammaglobulin, plasmapheresis, and cyclosporine.

In adults, colchicine and dapsone have also been used in patients with refractory chronic urticaria and urticarial vasculitis. Patients with chronic urticaria who have a positive autoantibody against Fc e R1α or IgE antibody are reported to have had good responses to cyclosporine.

The use of combined therapies to manage chronic urticaria has been reported. For example, one case was successfully managed with combination of antifibrinolytic agent (epsilon-aminocaproic acid) and montelukast plus the H2 antihistamine ranitidine.11 Two more reports indicated the efficacy of montelukast, and one additional study reported the efficacy of a combination of montelukast and a long-acting H1 antihistamine.12,13,14

Also, one report indicated that theophylline, a nonspecific phosphodiesterase inhibitor, could provide additional benefit if coadministered with a conventional H1 antihistamine.15 Unfortunately for pediatric patients, more clinical trial may be needed.

Therapeutic options for chronic urticaria have been extensive reviewed. An evidence-based review indicated second-line and third-line agents should be considered only in patients with chronic urticaria who are both severely affected and unresponsive to antihistamines. It was concluded that additional monitoring for toxicity is important in management with drugs other than antihistamines. Safety with second-line and third-line agents is favorable compared with corticosteroids.16,17

The alternative drugs for second-line and third-line consideration include leukotriene modifiers, sulfone (Dapsone), 5-aminosalicylic acid, chloroquine, colchicine, calcineurin inhibitors (eg, cyclosporine, tacrolimus), mycophenolate, and corticosteroids. The study populations were relatively small in these studies, and no study using the drugs mentioned above has been conducted in pediatric patients.

Leukotriene receptor antagonists

In recent years, leukotriene receptor antagonists (eg, montelukast) have been added to antihistamines to control urticaria.


Montelukast (Singulair)

Potent and selective antagonist of leukotriene D4 (LTD4) at the cysteinyl leukotriene receptor, CysLT1. Prevents or reverses some of the pathologic features associated with the inflammatory process mediated by leukotrienes C4, D4, and E4. Available as tab, chewable tab, or PO granules. Granules may be administered directly in the mouth or dissolved in 1 tsp of cold or room-temperature baby formula, breast milk, or food (stable with applesauce, carrots, rice, or ice cream).

Adult

10 mg PO qhs

Pediatric

<2 years: Not established
2-5 years: 4 mg PO qhs
6-14 years: 5 mg PO qhs
>14 years: Administer as in adults

Potent CYP450 inducers (eg, phenobarbital, rifampin) may reduce montelukast AUC

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adults may develop symptoms of upper respiratory infection; common adverse effects in children include headache, otitis media, or pharyngitis

Neuropsychiatric events have been reported; following further FDA evaluation, the prescribing information has been updated to include case reports during postmarketing surveillance that include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor

Antihistamines

These agents are used to treat urticaria and pruritus. Classic H1-blocker antihistamines block the histamine-mediated increase in vascular permeability. Some second-generation antihistamines may also reduce the release of vasoactive amines.


Hydroxyzine (Atarax)

Used for control of pruritus. Acts by competitive inhibition of histamine at the H1 receptor, which mediates the wheal-and-flare reactions.

Adult

25 mg PO tid/qid

Pediatric

2-4 mg/kg/d PO divided tid/qid

CNS depression may increase with alcohol or other CNS depressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, peptic ulcer, urinary tract obstruction, or hyperthyroidism; associated with clinical exacerbations of porphyria (may not be safe in patients with porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness


Diphenhydramine (Benadryl)

Used to control pruritus. Acts by competitive inhibition of histamine at the H1 receptor, which mediates the wheal-and-flare reactions.

Adult

25-50 mg PO q6-8h; not to exceed 400 mg/d

Pediatric

5 mg/kg/d PO divided tid/qid

Potentiates effect of CNS depressants; because of alcohol content, do not administer syr to patients taking medications that can cause disulfiramlike reactions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, or urinary tract obstruction; xerostomia, dizziness, or drowsiness may occur


Cetirizine (Zyrtec)

Nonsedating long-acting antihistamine. Acts by competitive inhibition of histamine at the H1 receptor.

Adult

5-10 mg PO qd or divided bid

Pediatric

<2 years: Not established
2-5 years: 2.5 mg PO qd; may increase dose; not to exceed 5 mg PO qd or divided bid
>6 years: Administer as in adults

May increase toxicity of CNS depressants; theophylline may decrease metabolism

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic or renal dysfunction (decrease dose); doses >10 mg/d are more likely to cause drowsiness


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 uncomplicated skin manifestations of chronic idiopathic urticaria.

Adult

5 mg PO qd in evening
CrCl 50-80 mL/min: 2.5 mg (half tab) PO qd in evening
CrCl 30-49 mL/min: 2.5 mg PO qod
CrCl 10-29 mL/min: 2.5 mg PO 2 times/wk

Pediatric

<6 years: Not established
6-11 years: 2.5 mg (half tab) PO qd in evening
>12 years: Administer as in adults

Coadministration with CNS depressants (eg, alcohol, sedative-hypnotics) may increase somnolence; ritonavir increased plasma AUC of measurable cetirizine by 42% and half-life by 53%

Documented hypersensitivity; CrCl <10 mL/min or hemodialysis; children aged 6-11 y with renal impairment

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Common adverse effects include somnolence, nasopharyngitis, fatigue, xerostomia, and pharyngitis in adults and children >12 y; pyrexia, somnolence, cough, and epistaxis commonly observed in children 6-12 y; caution with activities requiring mental alertness

Sympathomimetic agents

These agents cause vasoconstriction and reduction in vascular dilation, which contributes to urticaria formation.


Epinephrine (EpiPen)

Administered in severe or generalized urticaria as part of anaphylactic reaction. Available in an auto-injector form (EpiPen). EpiPen 1:1000 (ie, 1 mg/mL delivers 0.3 mg) is used for those who weigh >30 kg; EpiPen Jr 1:2000 (ie, 1 mg/2 mL delivers 0.15 mg) intended for children who weigh <30 kg.
DOC for the treatment of anaphylactoid reactions. The alpha agonist effects of this medication increase peripheral vascular resistance and reverse peripheral vasodilatation, vascular permeability, and systemic hypotension. Conversely, the beta agonist effects of epinephrine produce bronchodilatation, cause positive inotropic and chronotropic cardiac activity, and result in an increased production of intracellular cAMP.

Adult

0.01 mg/kg (ie, 0.01 mL/kg) IM/SC of 1:1000 solution; not to exceed 0.5 mg/dose (ie, 0.5 mL/dose); may repeat dose in 20 min prn; not to exceed a cumulative dose of 1 mg (ie, 1 mL)

Pediatric

0.01 mg/kg/dose SC; may repeat dose in 20 min prn; not to exceed a cumulative dose of 0.5 mg (ie, 0.5 mL)

Increases toxicity of beta- and alpha-blocking agents and of halogenated inhalational anesthetics

Documented hypersensitivity; life-threatening cardiac arrhythmias; angle-closure glaucoma

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adverse effects include palpitations, jitteriness, or blood pressure elevation

Corticosteroids, systemic

These anti-inflammatory agents help decrease vascular dilation and tissue inflammation. They should be used only if the patient has progressive generalized urticaria that cannot be reversed with other drugs.


Prednisone (Deltasone, Meticorten, Orasone, Sterapred)

Use for short-term anti-inflammatory effect.
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.

Adult

5-60 mg/d PO qd or divided bid/qid

Pediatric

Up to 1 mg/kg/d PO qd or divided bid/qid for 5 d
For persistent symptoms, administer for 2-3 wk while gradually tapering the dose downward

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; coadministration with diuretics may cause hypokalemia; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (may need to increase prednisone dose)

Documented hypersensitivity; viral, fungal, or tubercular skin lesions; history of GI ulcer or bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse effects of long-term use in children include of weight gain, stunting of growth, hypertension, hair growth, and acne; children who receive long-term corticosteroids should have frequent physical examinations, including growth rate analysis; caution with hyperthyroidism, nonspecific ulcerative colitis, peptic ulcer, diabetes mellitus, or myasthenia gravis

More on Urticaria

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Treatment & Medication: Urticaria
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Multimedia: Urticaria
References
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Further Reading

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Keywords

urticaria, hives,  anaphylactoid reaction, angioedema, pruritus, chronic urticaria, acute urticaria, papular urticaria, physical urticaria, histamine, transient urticaria, arthralgia, Henoch-Schönlein purpura, thyroid autoimmunity, celiac disease, hypothyroidism, hyperthyroidism, Hashimoto thyroiditis, collagen vascular diseases, rheumatoid arthritis, systemic lupus erythematosus, SLE, dermatomyositis, Behçet disease, inflammatory bowel disease, dental abscess, sinusitis, aphthous stomatitis, cholinergic urticaria, hereditary angioedema, edema

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Contributor Information and Disclosures

Author

Shih-Wen Huang, MD, Medical Director of Allergy Service, Professor, Department of Pediatrics, Division of Immunology and Infectious Diseases, University of Florida College of Medicine
Shih-Wen Huang, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD, Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School
Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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