Treatment Pathway
Treatment of Acute Urticaria (Hives)
Acute urticaria is a sudden-onset allergic skin reaction causing raised, itchy welts. It usually resolves within 6 weeks and can be triggered by foods, medications, infections, or insect bites.
AAD (American Academy of Dermatology)BAD (British Association of Dermatologists)EDF (European Dermatology Forum)EAACI (Allergy and Clinical Immunology)NICE
Acute urticaria is a sudden-onset allergic skin reaction causing raised, itchy welts. It usually resolves within 6 weeks and can be triggered by foods, medications, infections, or insect bites.
First-Line Treatment Principles
- ✓Emollient therapy: cornerstone for atopic eczema (apply at least twice daily)
- ✓Topical corticosteroids: lowest effective potency; limit facial/flexural use to mild-potency
- ✓Biologic therapy (dupilumab, tralokinumab): for moderate-severe atopic eczema inadequately controlled on topicals
- ✓Step-up psoriasis: topicals → phototherapy → systemic (methotrexate, biologics)
- ✓Allergen immunotherapy (AIT): for allergic rhinitis, bee/wasp venom allergy, selected food allergies
Non-Pharmacological Management
- •Trigger identification and avoidance: house dust mite, pet dander, nickel, fragrance, food allergens
- •Regular emollient use: repair skin barrier; reduce infection and flare frequency in eczema
- •Phototherapy (NB-UVB): second-line for psoriasis, eczema, and vitiligo
- •Wet wrapping technique for severe eczema flares
- •Adrenaline auto-injector training for anaphylaxis-risk patients; medical alert identification
- •Dietary management: strict gluten-free diet for coeliac/dermatitis herpetiformis
- •Sun protection: SPF 30+ broad-spectrum for all inflammatory skin conditions
Treatment Goals
🎯Symptom control: itch, pain, sleep disturbance reduction
🎯Skin clearance: PASI 90 response target for biologics in psoriasis
🎯EASI-75 (75% reduction) in eczema
🎯Quality of life improvement: DLQI score reduction
🎯Anaphylaxis prevention: avoidance + adrenaline access + immunotherapy where appropriate
Monitoring Parameters
- ◆EASI/SCORAD: eczema severity scoring at each visit
- ◆PASI (Psoriasis Area Severity Index): baseline and at 12 weeks for biologic response assessment
- ◆Blood pressure and lipid monitoring for acitretin/ciclosporin in psoriasis
- ◆LFTs, FBC: methotrexate shared care monitoring
- ◆Skin cancer surveillance: regular full-body skin checks, especially in immunosuppressed
- ◆Patch testing for contact dermatitis: done at specialist patch test clinic
Escalation Criteria
- →Anaphylaxis: IM adrenaline immediately; call emergency services; antihistamine/hydrocortisone adjuncts
- →Erythrodermic psoriasis or pustular psoriasis: urgent hospitalisation; systemic immunosuppression
- →Eczema herpeticum: antiviral (acyclovir) urgently; consider hospitalisation
- →Inadequate response to topicals in psoriasis after 8–12 weeks → phototherapy or systemic referral
Special Populations
Children: eczema most common in childhood; parental emollient education critical; avoid high-potency steroids on face
Pregnancy: topical steroids (mild-moderate) acceptable; avoid retinoids and methotrexate; biologics: limited data
Elderly: thinner skin — use mild-potency topical steroids; increased photosensitivity risk
Immunocompromised: atypical presentations; increased skin cancer risk
Clinical Insights
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