Classification and Treatment of Urticaria: A Brief Review

Kjetil Kristoffer Guldbakke, MD; Amor Khachemoune, MD, CWS


Dermatology Nursing. 2005;17(5):361-364. 

In This Article

Pharmacologic Therapy

First-Line Therapies

The mainstay of treatment for urticaria is oral antihistamines as they reduce itch, wheal duration and numbers. Management is better achieved by taking antihistamines daily, not just when the patient is symptomatic. About 44% of patients report a good response, and 15% partial relief of symptoms (Humphreys & Hunter, 1998). Initially a minimally sedating second or third-generation antihistamine should be given at a once-daily oral dosing (see Table 3 ). Patients often have a preference of one over another. It is common practice to exceed the licensed dose in severely affected patients. As a general rule, antihistamines are safe, have few significant adverse effects, and drug interactions are rare. If possible, it is best to avoid all antihistamines in pregnancy, although none has proven teratogenic. If one is used, the consensus is that chlorpheniramine is among the safest.

Addition of a sedating class I antihistamine at night can be helpful when sleep is disturbed by itching (see Table 4 ). The use of a sedating antihistamine as monotherapy is less desirable due to impairment of cognitive function, including driving performance and concentration. The addition of a H2 antagonist to conventional H1 antihistamines may be helpful in some patients. Ranitidine is preferable to cimetidine as it does not interfere with hepatic metabolism or bind androgen receptors.

Second-Line Drug Therapies

Oral corticosteroids given in short-reducing courses may be needed for severe exacerbations not responding to full-dose antihistamines. Relatively high doses up to 20 mg to 30 mg of prednisone may be needed for control. An alternative is giving them at a low-dose alternative-day therapy. Long-term administration should be avoided (Henderson et al., 2000). Delayed-pressure urticaria and urticarial vasculitis both respond poorly to antihistamines, and steroids are justified for severe disease (Henderson et al., 2000; Kaplan 2004). In urticarial vasculitis about 50% of patients improve on NSAIDs; some may need systemic immunosuppressive therapy.

Doxepine, a tricyclic antidepressant, is used for its potent antihistaminic properties and highly sedative effect. It is commonly used in combination regimens, and preferentially administered at bedtime.

Many patients feel reassured in carrying an epinephrine pen for self-administration if they are prone to bad attacks. Montelukast can have a synergistic effect, especially in aspirin-sensitive urticaria. Nifedipine has a small effect in chronic urticaria, and is often used for patients with concomitant hypertension. Thyroxin has been reported to suppress CIU in patients with antithyroid autoantibodies, but the results are inconsistent. Danazol may be useful for severe cholinergic urticaria, but has many side effects.

Third-line (immunosuppressive) Therapies

Based on our appreciation that some patients have an autoimmune basis, immunosuppressive therapy is considered for patients with a severe disabling course. Cyclosporin at 2.5 to 5 mg/kg/day has a confirmed benefit in a double-blind study in about two-thirds of patients with CAU refractory to antihistamines. It also has proven valuable in autoantibody-negative patients (Greaves, 2000). Plasma pheresis has shown improvement in 6 of 8 patients, but relapse occurred after 6 to 8 weeks. IV immunoglobulin was beneficial for 9 out of 10 patients, and two were still clear after 3 years. Azathioprine and methotrexate may also have a therapeutic role. Optimal treatment protocols still must be developed and confirmed.


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