Ditch the steroids for urticaria

Summer is here. People are going out and eating strange food, getting stung by strange things, and in general, coming into the ED for interesting rashes.

Contrary to a previous post suggesting a longer taper for contact dermatitis, this paper suggests that steroids are well, quite bunk for urticarial rashes.

This French, two-center, randomized, double-blinded study look at 5mg of levocetirizine vs 5mg of levocetirizine plus 4 days of 40mg prednisone for acute urticaria of under 24 hours duration. Patients were excluded if they had angioedema or anaphylaxis – among a multitude of other things, such that only 100 of 710 potentially eligible patients were enrolled (exclusion criteria comprised of: a history of diabetes, peptic ulcer disease, pregnancy, and chronic kidney disease, among many others).

The authors note that in Italy (strangely, why not in France?) , 93% of patients presenting to the ED for urticaria received steroids in 2011 – which I imagine is probably slightly higher than what I would expect for US EDs. So they reasonably suggest that, hey, maybe we can lower steroid-related ADR’s if we find a way to decrease the number of times we prescribe them.

Basically, after 1 hour, 2 days, and 5 days, there was no difference in itch control or rash resolution between the two groups, and if anything, a trend towards better outcomes with levocitirizine alone (For instance, 62% with an itch score of zero for steroids + levocitirizine vs 76% in levocitirizine only at 2 days). Relapse rates were 30% vs 24% (steroids+levo vs levo only) during the first 5 days, which was not statistically significant.

Sadly, and oddly, they report that “one patient in the placebo group had vomiting and abdominal pain in the ED 1 hour after initiation of treatment. These symptoms were related to anaphylaxis, and the patient rapidly improved after a steroid injection.” … which as we know, probably was not anaphylaxis if it improved “rapidly” after steroids (and without adrenaline). But I digress…

Previously, there have only been two studies looking at steroid use for urticaria; This one showing earlier resolution with 3 days of prednisolene (unsure if this is prednisolone, prednisone, or something else) against 10mg of loratadine (94% vs 66% resolution at 3 days), and this one showing lower itch scores with 4 days of 40mg prednisone plus 25mg of hydroxyzine every 4-8 hours than hydroxyzine treatment alone.

I think this particular study lends some credibility to those of us that are steroid-averse, and probably lends to a reasonable discussion with patients that are concerned about getting steroids. Likewise, it is probably reasonable to do a single dose dexamethasone treatement and chase it with a short course of levocitirizine.