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Urticaria - Management
View all quick answers
Scenario: First episode of urticaria
Definition
- Urticaria is a localised or generalised superficial swelling of the skin (epidermis and mucous membranes) that results in an itchy rash.
What assessment do I need to make for a first episode of urticaria?
- Confirm the diagnosis and try to identify the underlying cause using a thorough history and examination.
- Exclude angio-oedema and anaphylaxis with systemic involvement (urgent admission needed) by examining the ears, nose, and throat; listening to the person's chest; measuring blood pressure and pulse. For more information see the CKS topic on Angio-oedema and anaphylaxis.
- Investigations are not usually required.
In depth
How should I treat a first episode of urticaria?
- Treatment is not needed if the episode is mild; acute urticaria is normally self-limiting, and is not serious or infectious.
- If symptomatic treatment is needed:
- Offer a non-sedating antihistamine to control daytime symptoms.
- Consider giving an additional sedative antihistamine at night if the itch is interfering with sleep.
- For severe symptoms:
- Give a short course of oral corticosteroids (e.g. prednisolone 40 mg daily for 3–5 days) in addition to the oral antihistamine.
- If rebound symptoms occur after a short course of corticosteroids seek specialist advice. Repeat courses of steroids are not recommended.
In depth
Which antihistamine should I use to treat urticaria?
- First choice: cetirizine, fexofenadine, or loratadine.
- Additional sedating antihistamine to aid sleep: chlorphenamine or hydroxyzine.
In depth
When should I refer someone with urticaria?
- Admit a person with urticaria and angio-oedema involving the airway and/or anaphylaxis. Start initial treatment with intramuscular adrenaline, if available.
- Refer to an immunologist or dermatologist when there is:
- Urticaria with angio-oedema not involving the airway.
- Acute urticaria which is severe and thought to be due to a food or latex allergy.
- Chronic persistent urticaria (usually lasting beyond 6 weeks) which is troublesome despite the use of antihistamines and avoidance of known trigger factors.
- Vasculitic urticaria: suspect if lesions are painful and persistent.
In depth
Prescriptions
Non-sedating oral antihistamines
Age from 2 years to 5 years 11 months
Cetirizine s/f solution: 5mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take one 5ml spoonful once a day.
Supply 100 ml.
Loratadine syrup: 5mg once a day
Loratadine 5mg/5ml oral solution
Take one 5ml spoonful once a day.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Cetirizine s/f solution: 10mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Loratadine syrup: 10mg once a day
Loratadine 5mg/5ml oral solution
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Age from 12 years onwards
Cetirizine tablets: 10mg once a day
Cetirizine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Fexofenadine tablets: 180mg once a day
Fexofenadine 180mg tablets
Take one tablet once a day.
Supply 14 tablets.
Loratadine tablets: 10mg once a day
Loratadine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Sedating oral antihistamines (for itch at night)
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age from 1 year 1 month to 1 year 11 months
Chlorphenamine oral solution: 1 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age from 2 years to 5 years 11 months
Chlorphenamine oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Chlorphenamine oral solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Short course of oral prednisolone (children)
Age from 1 month to 1 year 11 months
Prednisolone soluble tablets: 10mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 3 days.
Supply 6 tablets.
Age from 2 years to 5 years 11 months
Prednisolone soluble tablets: 20mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take four tablets each morning (as a single dose) for 3 days.
Supply 12 tablets.
Age from 6 years to 11 years 11 months
Prednisolone soluble tablets: 30mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take six tablets each morning (as a single dose) for 3 days.
Supply 18 tablets.
Prednisolone soluble tablets: 40mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Short course of oral prednisolone (adults)
Age from 12 years onwards
Prednisolone tablets: 40mg each morning for 3 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone tablets: 50mg each morning for 3 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone tablets: 40mg each morning for 5 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone tablets: 50mg each morning for 5 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Prednisolone e/c tablets: 40mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone e/c tablets: 50mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone e/c tablets: 40mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone e/c tablets: 50mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Scenario: Recurrent or persistent urticaria
Definition
- Recurrent or persistent urticaria that lasts for more than 6 weeks is called chronic urticaria.
What assessment do I need to make for recurrent or persistent urticaria?
- Assess the severity of symptoms and their impact on daily living and psychological well-being.
- Although it is not always possible, try to identify the underlying cause using a detailed history and examination.
- Consider the following investigations to determine a possible cause: full blood count (FBC), stool sample, erythrocyte sedimentation rate (ESR), thyroid function tests (TFTs, including autoantibodies), and liver function tests (LFTs) and Helicobacter pylori screening if gastrointestinal symptoms are present.
- Identify any ongoing trigger factors such as stress, alcohol, foods, and medication.
- Consider referring people to an immunologist or dermatologist, depending on local policy.
In depth
How should I treat recurrent or persistent urticaria?
- Manage any underlying associated diseases (e.g. H. pylori infection, thyroid disease, connective tissue disorder), although there is limited evidence that correcting these conditions will improve the urticaria itself.
- Offer a non-sedating antihistamine to control daytime symptoms.
- Consider giving an additional sedating antihistamine at night if the itch is interfering with sleep.
- Topical menthol 1% cream can be used as an alternative to, or in addition to, an oral antihistamine.
- For a severe 'flare up', give a short course of oral corticosteroids (e.g. prednisolone 40 mg daily for 3–5 days) in addition to an oral antihistamine.
- If rebound symptoms occur after a short course of corticosteroids seek specialist advice. Repeat courses of steroids are not recommended.
In depth
Which antihistamine should I use to treat urticaria?
- First choice: cetirizine, fexofenadine, or loratadine.
- Additional sedating antihistamine to aid sleep: chlorphenamine or hydroxyzine.
In depth
What self-care advice should I give for urticaria?
- Identify and avoid trigger factors such as stress, alcohol, caffeine, spices, certain foods, overheating, medications (e.g. angiotensin-converting enzymes, aspirin, codeine, nonsteroidal anti-inflammatory drugs).
- Try not to scratch — rub skin with palms of hands, keep nails short and clean.
- Choose clothing that does not irritate the skin (e.g. cotton).
- If skin creams or detergents worsen symptoms, use lubricating, alcohol-free, hypoallergenic products.
- Consider the use of calamine lotion to soothe itch.
In depth
What follow-up is recommended for recurrent or persistent urticaria?
- If urticaria recurs or persists (usually beyond 6 weeks) and is troublesome despite antihistamines and avoidance of known trigger factors, refer to an immunologist or dermatologist.
- Any suggestion of angio-oedema will require admission to hospital or daily review until symptoms resolve. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
In depth
When should I refer someone with urticaria?
- Admit a person with urticaria and angio-oedema involving the airway and/or anaphylaxis. Start initial treatment with intramuscular adrenaline, if available.
- Refer to an immunologist or dermatologist when there is:
- Urticaria with angio-oedema not involving the airway.
- Acute urticaria which is severe and thought to be due to a food or latex allergy.
- Chronic persistent urticaria (usually lasting beyond 6 weeks) which is troublesome despite the use of antihistamines and avoidance of known trigger factors.
- Vasculitic urticaria: suspect if lesions are painful and persistent.
In depth
Prescriptions
Non-sedating oral antihistamines
Age from 2 years to 5 years 11 months
Cetirizine s/f solution: 5mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take one 5ml spoonful once a day.
Supply 150 ml.
Loratadine syrup: 5mg once a day
Loratadine 5mg/5ml oral solution
Take one 5ml spoonful once a day.
Supply 150 ml.
Age from 6 years to 11 years 11 months
Cetirizine s/f solution: 10mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take two 5ml spoonfuls once a day.
Supply 300 ml.
Loratadine syrup: 10mg once a day
Loratadine 5mg/5ml oral solution
Take two 5ml spoonfuls once a day.
Supply 300 ml.
Age from 12 years onwards
Cetirizine tablets: 10mg once a day
Cetirizine 10mg tablets
Take one tablet once a day.
Supply 28 tablets.
Fexofenadine tablets: 180mg once a day
Fexofenadine 180mg tablets
Take one tablet once a day.
Supply 28 tablets.
Loratadine tablets: 10mg once a day
Loratadine 10mg tablets
Take one tablet once a day.
Supply 28 tablets.
Sedating oral antihistamines (for itch at night)
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age from 1 year 1 month to 1 year 11 months
Chlorphenamine oral solution: 1 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age from 2 years to 5 years 11 months
Chlorphenamine oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Chlorphenamine oral solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Topical antipruritic
Age from 1 month onwards
Menthol 1% in aqueous cream: apply once or twice a day
Menthol 1% cream
Apply to the affected area(s) once or twice a day.
Supply 500 grams.
Short course of oral prednisolone (children)
Age from 1 month to 1 year 11 months
Prednisolone soluble tablets: 10mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 3 days.
Supply 6 tablets.
Age from 2 years to 5 years 11 months
Prednisolone soluble tablets: 20mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take four tablets each morning (as a single dose) for 3 days.
Supply 12 tablets.
Age from 6 years to 11 years 11 months
Prednisolone soluble tablets: 30mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take six tablets each morning (as a single dose) for 3 days.
Supply 18 tablets.
Prednisolone soluble tablets: 40mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Short course of oral prednisolone (adults)
Age from 12 years onwards
Prednisolone tablets: 40mg each morning for 3 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone tablets: 50mg each morning for 3 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone tablets: 40mg each morning for 5 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone tablets: 50mg each morning for 5 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Prednisolone e/c tablets: 40mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone e/c tablets: 50mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone e/c tablets: 40mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone e/c tablets: 50mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
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