Management of Urticaria

Initial diagnostic testing

  • Complete blood count with differential
  • ESR or CRP
  • Infectious disease workup (symptom-directed only; this is particularly important in children because of the high frequency of streptococcal or mycoplasma infection in association with urticaria)
  • Diagnostic maneuvers for cold or physical urticaria
  • Only limited additional testing as indicated by history and/or physical exam

First-line therapy: non-sedating H1-antihistamines (second generation)

  • Start with standard dosing
  • Escalate up to 4-fold dosing
  • Add a second agent

Initial therapy

  1. Treat with a non-sedating H1 antagonist antihistamine:
    • Loratadine (such as Claritin) 10 mg
    • Fexofenadine (such as Allegra) 180 mg
    • Cetirizine (such as Zyrtec) 10 mg
    • Levocetirizine (such as Xyzal) 2.5 mg
  2. Consider escalating the dose up to 4-fold dosing after 2 weeks. There is current data supporting that dose-escalation is effective for some, but not all, non-sedating H1 antihistamines.
  3. If urticaria is suppressed, treat the patient continually in order to maintain control of the process, with a slow taper once symptoms fully subside.
  4. Systemic steroids (such as prednisone) may be necessary for 3-7 days for severe, acute flares.
  5. Sedating H1 antagonist antihistamines are no longer recommended as first-line or long-term treatment of urticaria because of adverse effects associated with their use (such as sedation, anticholinergic effects) and due to the high efficacy and wide availability of non-sedating antihistamines.
    • Hydroxyzine (such as Atarax) 25 mg t.i.d. or q.i.d. with gradual dose escalation every 3-4 days to a maximum of 200 mg/day.
    • Diphenhydramine (such as Benadryl) 25 mg t.i.d. or q.i.d.
    • Doxepin (such as Sinequan). Begin therapy with 25 mg b.i.d. and increase the dose every 4-5 days to a maximum of 50 mg t.i.d. Because doxepin can prolong the PR interval and worsen conduction defects, obtain an EKG prior to therapy.

Subsequent therapy

  1. Add a leukotriene inhibitor, like montelukast (such as Singulair) 10 mg q day
  2. There is some evidence to support addition of other agents such as:
    • H2 antagonist antihistamine (such as ranitidine, famotidine, cimetidine)
    • Cyclosporine (such as Neoral or Sandimmune)
    • Dapsone
    • Hydroxychloroquine (such as Plaquenil)
    • Omalizumab (such as Xolair)
  3. A regimen with multiple agents in combination may be necessary to control symptoms.

When to refer to a dermatologist

  • If the diagnosis of urticaria is unclear.
  • For clarifying the diagnosis in rare cases of urticaria clearly in association with systemic symptoms (i.e., arthritis, fever, bone pain, paraproteinemia, ocular or other neurologic symptoms).
  • For long-term management of long-term urticaria, especially if it is highly steroid-dependent.