How to treat urticaria

Frequently, urticaria will resolve on its own without any treatment.
Treatment of urticaria involves identifying and avoiding the triggers and using some medications.

TREATING TRIGGERS AND CAUSES

See “trigger” section in diagnosis.
In such cases, patients should avoid the trigger as far as possible in addition to taking medications.
If the cause is identified as something else, such as an infection, this should obviously be treated or stopped.

Non-Pharmacological Management

If urticaria can be tolerated without medical treatment, a few helpful points should be considered by the patient:

  • A. Do not scratch the itchy urticarial lesions and keep as cool as possible by applying cold water (not iced), lotion, and wearing loose-fitting clothing.
  • B. Avoid wine and alcoholic drinks and tobacco, which non-specifically can trigger urticaria.
  • C. Avoid perfumed emollients, antihistamine creams, and Lanolin (to avoid contact allergy).
  • D. Avoid physical triggers if known.
  • E. Try to keep “stress” under control with remediation, relaxation exercises, and Yoga.
  • F. Avoid foods and some medications with preservatives and colorings (Tartrazine), additives (Sodium Benzoate and Sulfites), and natural Salicylate (Berry fruit, Spices, and strong Tea). Trying a pseudoallergen-free diet for at least three weeks may reduce symptoms and the burden of pharmacological medication use in 1/3 of patients. The pseudoallergen-free diet contains more fresh food and eliminates processed foods, additives, dyes, preservatives, phenols, and certain aromatic compounds.
  • G. Avoid aspirin-containing medication and flu-remedies and other anti-inflammatory medication (NSAIDs) such as Ibuprofen, Mefenamic acid and diclofenac, and Codeine (opiate analgesics) which may also act as urticaria triggers.
Medications

Antihistamines are effective medications for symptom relief from hives. There are several medications in this group with similar effects.
Second-generation antihistamines are the most commonly prescribed medication for hives. These include cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine which are tablets taken orally. These medications may uncommonly cause side effects like sleepiness and dizziness in varying degrees; however, most people do not experience these effects. Fexofenadine is among the most non-sedating agent.
Other non-sedating antihistamines include ebastine, bilastine and rupatadine.
First-generation antihistamines like diphenhydramine, hydroxyzine, and chlorpheniramine are also effective but cause significant sleepiness. These medications may also be administered via injection. Anti-depressant medications with antihistaminic effects such as doxepin can be used.
In some cases, a short course of low-dose steroids may be recommended.
For patients who have hives as part of a severe allergic reaction/anaphylaxis, an adrenaline auto-injector (Epipen) will be prescribed.

Management of Chronic Urticaria

In the case of chronic urticaria (where hives persist for more than six weeks), patients are advised to use second-generation antihistamine tablets regularly. If symptoms are not controllable, a high dose initially, up to four tablets per day of a standard dose tablet, can be used. Alternatively, another sedating type of antihistamine at night is added. Sedation and tendency for sleepiness are usually becoming less after a regular intake for a while.

For those unable to do so or who do not respond to this treatment, omalizumab injections may be used. Omalizumab is a biologic drug (monoclonal antibody against immunoglobulin E) administered as a monthly injection.
In resistant cases to the above medication, your doctor may consider options like immunosuppressants, immunomodulators, and/or anti-inflammatory agents (e.g., cyclosporine, dapsone, sulfasalazine, etc.) to achieve better symptoms control.

Prognosis

Most cases of acute urticaria improve within a few days, even without treatment.
Chronic urticaria may take longer to resolve; in most cases, it improves within one year. Some patients experience waxing and waning of symptoms from time to time.
Certain factors may exacerbate hives in patients with pre-existing urticaria, e.g., some antibiotics or painkillers (Non-Steroidal Anti-Inflammatory Drugs such as diclofenac and ibuprofen).
Disease control is achieved with most of the antihistamine if appropriately used. Common reasons for treatment failure regarding antihistamine are that the antihistamine used is not strong enough, the dose is not high enough, or not continued for enough time.
In general, most patients with chronic urticaria are respondents to antihistamines alone and have a favorable prognosis and outcome.

Patient education and understanding of the natural history of the disease are important in the management of urticaria. Chronic urticaria is an annoying problem for the patient as well as the treating physicians. Patients continue to visit multiple specialists and believe that something is causing these hives. In summary, the great majority of cases of chronic hives (urticaria) have no cause. As in most patients, no cause is found; the urticaria management aims to find a safe medication regimen that controls the hive until it spontaneously resolves by itself.