Initial treatment of acute and chronic hives with or with-out angioedema relies upon oral H1 antihistamines. For many years, physicians believed that the older, sedating antihistamines, such as diphenhydramine and hydrox-yzine, were more effective for treating hives than the newer nonsedating medications. However, a great body of research has demonstrated that this is not the case.
Therefore, I always start the patient on a single daily dose of a nonsedating (loratadine, desloratadine, fexofenadine) or minimally sedating (i.e., cetirizine, levocetirizine) anti-histamine. If these are not completely effective in relieving the hives and itching, I will then add an oral H2 antihistamine, such as ranitidine or cimetidine, in a single daily dose. Most patients recognize these medications as acid blockers for treating stomach ulcers or gastro-esophageal reflux disease.
However, there are also H2 histamine receptors in the skin, and blocking these receptors adds significant benefit in controlling the hives. If a combination of H1 and H2 antihistamines does not completely control the hives and/or angioedema, the most commonly prescribed third-line medication is montelukast. While montelukast is not currently approved by the Food and Drug Administration (FDA) for the treatment of hives, it has proven helpful in many patients and is generally very well tolerated.
If the combination of these three classes of medications is still not successful and the hives are quite severe, then a course of oral prednisone, 0.5 mg/kg/day is given for 5 to 7 days. In patients with chronic hives, the hives may recur after the prednisone is finished, making it tempting to continue treatment with prednisone. How-ever, prednisone is plagued with many side effects that make it an undesirable choice for long-term use.
Alter-natives to chronic treatment with prednisone include hydroxycholorquine and cyclosporine, both of which are well tolerated by most patients but require ongoing monitoring to ensure patient safety. Given the possibility of occasionally serious side effects, these medications should only be prescribed by physicians who are experienced in their use and feel that all other alternatives have been considered.
Martin’s comment: I’ve had hives for the last 4 weeks. Since I didn’t have a doc-tor when they started, I figured it was caused by my soap or detergent or body cream, and I switched those around. I was still having the hives, so I checked for bedbugs or some kind of mite, and everything seemed to be fine with my bedding. A friend told me to take Chlor-Trimeton pills from the pharmacy, and it did help some, but I felt tired all of the time.
Since I was now itchy and tired, I saw a doctor at an urgent care, and she recommended over-the-counter pills called loratadine and ranitidine. I took one 10 mg pill of the loratadine in the morning and two 75 mg pills of ranitidine twice per day, and after a day I felt 75% better. I’m 25 years old and healthy, and my physical exam was normal, so the doctor told me that she would treat the condition with these pills for a few weeks and see me back before ordering any tests.