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Three Part Question

Do [steroids] [reduce symptom duration of acute urticaria] in [adult patients presenting to the emergency department]?

Clinical Scenario

A 28 year old female attends the Emergency department with widespread red, itchy wheals covering her body. She is unsure of what has caused this and it has not happened before to this extent. She is haemodynamically stable and has no airway or respiratory involvement. She is visibly uncomfortable and you want to help the symptoms
resolve as quickly as possible.

You are unsure of the clinical evidence behind a course of oral steroids for acute urticaria and NICE CKS suggests it on expert advice.

Search Strategy

MEDLINE (from 1966) using PubMed interface. We then carried out a Cochrane Library search and a Grey Literature search on Google Scholar.
"urticaria"[MeSH Terms] AND "steroid*"[MeSH Terms] AND ("emergency service, hospital"[MeSH Terms] OR ("emergency"[All Fields] AND "service"[All Fields] AND "hospital"[All Fields]) OR "hospital emergency service"[All Fields] OR ("emergency"[All Fields] AND "department"[All Fields]) OR "emergency department"[All Fields])

Search Outcome

The search of MEDLINE returned 34 papers, 4 of which were further analysed. One of these papers was a protocol and so was removed from final analysis. Cochrane review search presented no further studies, neither did Google Scholar. Inspection of the references to these papers brought up no further relevant studies.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Palungwachira P, Vilaisri K, Musikatavorn K, Wongpiyabovorn J 2020 Thailand	Adults (age 18-60) attending the emergency department with acute onset (<24 hours) urticaria without sign of angioedema or anaphylaxis. Treatment was IV Chlorphenamine vs IV chlorphenamine with IV dexamethasone vs IV chlorphenamine, IV dexamethasone and 5 days oral prednisolone on discharge. Outcomes measured by urticaria activity score at 1 week and 1 month.	RCT (1b)	Reduction in VAS (visual analogue scale) at 60 mins	No significant change in groups at 60 mins (p=0.454)	Single centre, small population (75 patients). Self-evaluation score. Unblinded home treatment.
			Reduction in VAS at 1 week	Patients with steroids TTO showed greater prevalence of urticaria at 1 week 29.2% CI (10.8% to 51.3%)
			Reduction in VAS at 1 month	Patients with steroids TTO showed greater prevalence of urticaria at 1 month 25.0% CI (7.4% to 47.0%)
Caroline Barniol, MD; Emilie Dehours, MD; Jean Mallet, MD; Charles-Henri Houze-Cerfon, MD; Dominique 2018 France	Adults (>18) attending ED with acute urticaria (<24 hours duration), without sign of anaphylaxis. Treatment with levocetirizine for 5 days with 5 days of prednisolone/placebo. Outcome measured at 2, 5, 15, 21 days by verbal numeric rating score for both itchiness and rash size.	RCT (1b)	Itching relief at 2 days	No significant difference in reduction of itch at 2 days (Difference 14%; 95% CI – 31% to 4%)	Telephone follow up. Small population (100 patients). Treatment was 5 days, primary outcome was at 2 days.
			Percentage reduction in rash at 2 days	No significant difference in rash resolution (Difference 8%; 95% CI –25% to 9%)
			Percentage reduction in rash at 5 days	No significant difference in rash resolution
C V Pollack Jr, T J Romano 1995 USA	Adults attending ED with acute urticaria (<24 hours), without evidence of anaphylaxis. Patients received IM diphenhydramine in department and discharged with oral hydroxizine and prednisolone/placebo for 4 days. Outcome of 'itch score' measured by visual analogue scale at 2 and 5 days	RCT (1b)	Reduction in VAS itch score at 2 days	Itch score reduction significant at 2 days (p= .0001 ANCOVA)	Single centre. Small population - 43 patients (24 vs 19)
			Reduction in VAS itch score at 5 days	Itch score reduction significant at 5 days (p= .0001 ANCOVA)

Comment(s)

These studies each have different treatment protocols, including different antihistamines which makes the findings difficult to implement. However each demonstrate the role of a course of oral prednisolone on discharge in reducing symptom duration. The studies do highlight potential side effects of steroids including gastrointestinal symptoms and fatigue/insomnia, but overall no significant harm was reported.

Clinical Bottom Line

There is no strong evidence for the use of oral steroids on discharge to reduce symptom duration in acute urticaria.

References

1. Palungwachira P, Vilaisri K, Musikatavorn K, Wongpiyabovorn J A randomized controlled trial of adding intravenous corticosteroids to H1 antihistamines in patients with acute urticaria AJEM Volume 42, April 2021, Pages 192-197
2. Caroline Barniol, MD; Emilie Dehours, MD; Jean Mallet, MD; Charles-Henri Houze-Cerfon, MD; Dominique Lauque, MD*; Sandrine Charpentier, MD, PhD Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial AEM 2018 Jan. 71(1); pates125-131
3. C V Pollack Jr, T J Romano Outpatient management of acute urticaria: the role of prednisone AEM 1995 Nov; 26(5):547-51