Treatment Progression for Chronic Hives

Reviewed by: HU Medical Review Board | Last reviewed: November 2022

The goal of treatment for chronic hives is to reduce symptoms while the condition lasts. Treatments will not cure chronic hives or reduce the duration of the condition. However, they can relieve symptoms and improve quality of life.

Experts suggest that treatment should progress along a stepwise approach. Your doctor will usually start with non-drowsy antihistamines. Then they will increase or decrease your treatments until symptoms are controlled. This will ensure adequate treatment while minimizing the risk of side effects.1

How do doctors decide between chronic hives treatments?

Doctors usually follow a stepwise approach to treatment. They will start with a therapy that is safe and controls symptoms for most people. They will then move up and down the steps depending on your response. This approach allows them to:1

  • Increase or decrease your dose of medicine
  • Combine a new drug with one you are already taking
  • Change to a different type of the same medicine
  • Stop a drug that does not work
  • Reduce medicine once symptoms are controlled

This strategy helps personalize your treatment. It ensures you receive as much treatment as you need but with the lowest risk for side effects. For that reason, all major guidelines recommend a stepwise approach.1

What are the steps in treatment progression?

All treatment guidelines have similar stepwise approaches. However, they have slight differences in certain steps. All steps of treatment should include avoiding any triggers and causes. However, the triggers and causes are not always known.2,3

At any step of treatment, your doctor may suggest short-term corticosteroids (steroids). These can help briefly control severe symptoms. However, they should not be used long-term because of potential side effects.1

Step 1

Treatment usually will start with a non-drowsy antihistamine at the standard dose. Many options are available. Some people respond differently to different options. You may need to try a few before your doctor decides whether antihistamines work for you.2,4

Many studies have shown that antihistamines are an effective treatment for chronic hives. They are most effective when taken daily. If antihistamines control symptoms, you may continue treatment for several weeks to months. Your doctor may occasionally stop treatment to see if your hives have gone away on their own.1,4

Step 2

If the first step does not control symptoms within 2 to 4 weeks, your doctor will move to step 2. Different guidelines have slightly different recommendations. For example, international guidelines recommend increasing the dose of the non-drowsy antihistamine. However, increasing the dose does not seem to work for all antihistamines.3

U.S. guidelines suggest a few different options at this step. Some possible treatment changes include:2

  • Increasing the dose of a non-drowsy antihistamine up to 2-4 times the original dose
  • Combining 2 different non-drowsy antihistamines
  • Add an H2 blocker
  • Add a leukotriene receptor antagonist
  • Add a drowsy antihistamine at bedtime

If any of these treatments control symptoms, you may take them for several months. Your doctor may then try to gradually reduce your treatment.1

Step 3

If the second step does not control symptoms within 2 to 4 weeks, your doctor will move to step 3. Your doctor may stop any drugs from step 2 that did not have any benefits. Guidelines differ on what else to try at this step.1

International guidelines recommend adding omalizumab (Xolair®) to non-drowsy antihistamines. Clinical trials have shown that it is beneficial and safe in people whose symptoms are not controlled by antihistamines. Xolair is given by injection under the skin (subcutaneously) every 4 weeks.3

U.S. guidelines recommend increasing the dose of the drowsy antihistamine at this step. These drugs are convenient and helpful for many people. However, they may not be a safe option for children and older adults.2

If any of these treatments control symptoms, you may take them for several months. Your doctor may then try to gradually reduce your treatment.1

Step 4

If the third step still does not control symptoms, you are considered to have "refractory" chronic hives. This means it does not respond to any dose of any antihistamines. Your doctor will consider several therapies. Some possibilities include:2,3,5

There are many additional therapies that are reported to be useful in chronic hives treatment. However, they all have a high cost, limited evidence of benefits, or serious side effects. This is why current guidelines do not recommend using them except in very specific situations.2-4

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