Treatment of Hives

Urticaria (hives) is a medical condition characterised by a presence of hives (weals) or angioedema. A weal refers to the skin-coloured or light pink swelling, which is usually surrounded by redness (erythema). The swelling lasts from a few minutes to 24 hours depending on the individual and severity of the case.

The initial treatment for all forms of hives for all age groups is usually conducted with oral second-generation antihistamines, such as Cetirizine, Rupatadine, Desloratadine, and others in a standard dose. However, if the standard dose is not effective, it can be increased according to the prescribing physician's recommendations. The medications must be taken until urticaria has settled.

First-generation antihistamines (e.g., chlorpheniramine and promethazine) are no longer recommended for the treatment of hives. These medications are short-lasting and have sedative side effects. Sleep, performance, and learning are reported to be impaired, and records of lethal overdoses have been documented.

In addition to using antihistamines, triggering factors of urticaria should be eliminated if known. Potential drug and food allergies should be removed. If relevant type 1 allergens are eliminated, hives will typically clear within 48 hours. The affected area is advised to be cooled with a fan, ice pack, cold flannel, or a soothing moisturising lotion.

Physical triggering agents are recommended to be minimised as much as possible. To reduce friction, tight clothing should be avoided. For cold urticaria, careful dressing for cold and windy conditions is recommended, as is avoiding swimming in cold water. For solar urticaria, sun-exposed areas should be covered and broad-spectrum sunscreens applied.

Acute refractory urticaria lasts for less than 6 weeks. Non-sedating antihistamines are typically the primary treatment option. If they are not effective at the optimised dose, a short course of oral prednisone or systemic cyclosporine may be used. Intramuscular injection of adrenaline is reserved for emergency situations, such as throat swelling.

Chronic urticaria refers to a type of urticaria characterised by daily or episodic weals lasting more than 6 weeks. Second-generation oral antihistamines are the primary treatment. If a patient does not respond to the maximum dosage of second-generation oral antihistamines after 4 weeks, further treatment should be pursued and a referral to a specialist physician, such as a dermatologist, medical allergy specialist, or immunologist, is indicated.

Recent advances in the treatment of urticaria include the biologic medication Omalizumab, which has shown good evidence in treating patients with urticaria who are resistant to antihistamine medications.

The effectiveness of each treatment can be objectively evaluated through the urticaria control test. Patients are asked to rate their symptoms over a four-week period, including quality of life and overall control of urticaria.