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Three Part Question

In a [child with acute urticaria] does the [addition of oral steroids to antihistamines] lead to [more rapid resolution of symptoms]?

Clinical Scenario

A 4 year old girl presents to the Emergency Department with an urticarial rash. Her general practitioner has prescribed an oral antihistamine but the rash has persisted. You wonder if there is a role for oral steroids in this otherwise well child.

Search Strategy

Cochrane Database of Systematic Reviews Issue 3, 2003. Medline 1966-10/03 using the OVID interface.
Cochrane: 'urticaria'
Medline: [exp urticaria OR urticaria$.mp] AND [exp steroids OR steroid$.mp OR exp adrenal cortex hormones OR corticosteroid$.mp] AND [Randomized Controlled Trial.pt OR Controlled Clinical Trial.pt] LIMIT to human.

Search Outcome

Cochrane Database of Sytematic Reviews - no relevant results
Medline search results – 39 articles, of which 2 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pollack CV Jr & Romano TJ, 1995, USA	43 adult outpatients with acute urticaria given im. diphenhydramine then randomised to oral hydroxyzine plus either 20mg prednisone 12hrly for 4 days or placebo	RCT	10 point visual analogue Itch score at 48 hours	Mean 48 hour itch score 1.3 in prednisone group vs 4.4 in control group	Adult patients only Small study No power calculation Rash not described at 5 days in control group
			Itch score at 5 days	5 day itch score 0 in prednisone group vs 1.6 in control group
			Description of rash at 48 hours and 5 days	No difference between groups at 48 hours.Rash resolved completely at 5 days in prednisone group
Zuberbier T et al, 1996, Germany	109 adult and paediatric patients with acute urticaria treated with loratidine 10mg daily or prednisolone 50mg daily for 3 days followed by loratidine 10mg daily until remission of symptoms	Non-randomised prospective cohort study	Days until cessation of whealing	65.9% of had cessation of whealing by 3 days and a further 15.9% by 7 days in Loratidine group, compared with 93.8% by 3 days and a further 3.1% by 7 days in the prednisolone group. Resolution in all patients after >21 days. NNT with prednisolone for resolution of symptoms by 3 days = 4	Number of children unstated Different exclusion criteria between groups (potentially pregnant women excluded from loratidine group)

Comment(s)

There are no studies specifically aimed at children with acute urticaria. These limited trials demonstrate improvement in symptoms when prednisolone is prescribed, but larger studies are needed.

Clinical Bottom Line

In patients presenting to the emergency department with acute uricaria, the addition of oral prednisolone to an antihistamine results in decreased itch and more rapid rash resolution.

References

1. Pollack CV Jr, Romano TJ. Outpatient management of acute urticaria: the role of prednisone. Ann Emerg Med 1995;26(5):547-51.
2. Zuberbier T, Ifflander J, Semmler C, et al. Acute urticaria: clinical aspects and therapeutic responsiveness. Acta Derm Venereol 1996;76(4):295-7.