Treatment of Hives

To treat hives, we first use oral medications, and if these have little effect, we use injectable drugs.

Oral therapy

Antihistamines

Topical medications are not effective for hives. Oral antihistamines are the first choice. Among the so-called second-generation group, which has fewer side effects, we mainly use the drugs described as non-sedating. There are many types, and we try them while watching their efficacy and side effects.

Some drugs cause drowsiness as a side effect, and because brain function may become sluggish even without your being aware of drowsiness, you cannot drive a car or operate heavy machinery while taking these drugs. To avoid interfering with your daily life or work, it is good to choose ones that cause little drowsiness and ones with a dosing regimen that fits your routine so you are less likely to forget. Side effects vary by drug, but in addition to drowsiness they include dry mouth, impaired liver function, and impaired kidney function.

If you do not get an effect, we change the antihistamine or increase the dose. If you stop just because the eruptions have stopped appearing, the symptoms can come back. When stopping the medication, follow your doctor’s instructions and taper it gradually before quitting.

Also, taking the medication only when symptoms appear has no value as treatment, because it does not reduce how often symptoms occur. Take it as directed. For pregnant and breastfeeding women, we select and administer drugs with a high safety profile. In children, the eruptions often stop appearing after a short course, but some children continue for more than several months, in which case we continue the medication while watching for side effects.

Oral steroids

When symptoms cannot be controlled even with antihistamines and supplementary drugs, oral steroids may be used. The dose takes body weight into account. However, because long-term oral steroids can cause many side effects such as high blood pressure, diabetes, high blood lipids, central obesity, and osteoporosis, they should be stopped within a short period of one month. Yet because symptoms worsen when steroids are stopped, people sometimes drag on taking them, which becomes a problem. Long-term administration should be avoided especially in children.

Injection therapy (biologic drugs)

Omalizumab

Omalizumab® (Xolair) subcutaneous injection is classified as a biologic drug.

Unlike conventional drugs, which are chemically synthesized, biologic drugs are manufactured using the cells of living organisms; in the case of Xolair, Chinese hamster ovary cells are used. This drug is an anti-IgE antibody: by blocking IgE, an immune-related protein, it prevents IgE from binding to cells called mast cells and triggering the release of histamine, the itch-causing substance. This drug is indicated in treatment-resistant cases where the cause, such as a food or a physical stimulus, cannot be identified and eruptions with intense itching that interfere with daily life keep appearing despite oral antihistamines.

It is administered as a subcutaneous injection once every four weeks. If there is no effect after 12 weeks, we consider stopping it.

This drug is also used to treat bronchial asthma, and using it to treat hives affects the serum IgE level used as a reference in treating bronchial asthma. Starting or stopping this drug can also affect asthma symptoms. Therefore, patients who also have asthma should consult their attending physician in internal medicine or respiratory medicine and obtain permission before starting. Do not stop treatment or visits for asthma or other allergic conditions on your own just because you are using this drug.

There are also reports of anaphylaxis. Most cases occur within two hours of the injection, but some occur after more than two hours, so you need to watch for changes in your condition for a while after administration.

Other side effects include dizziness, fatigue, fainting, somnolence, nasopharyngitis, sinusitis, headache, and parasitic infection. Also, when oral steroids are being tapered down, a disease called eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) can appear. It cannot be administered to children under 12.

Dupilumab

Dupixent® (dupilumab) subcutaneous injection is an injectable drug that suppresses two cytokines, IL-4 and IL-13. It is indicated for idiopathic chronic urticaria, that is, hives of unknown cause that last more than six weeks.

For administration, only the first time you receive two subcutaneous injections, and thereafter one injection once every two weeks. Under a doctor’s guidance, you can self-inject, taking the drug home and injecting it yourself. If there is no effect after 24 weeks, we consider stopping it.

Side effects include herpes, conjunctivitis, keratitis, and rarely anaphylaxis. For pregnant and breastfeeding women, we carefully consider whether to administer it. It cannot be administered to infants under six months of age. Also, you cannot receive live vaccines while on this drug.