Depending on the duration of clinical symptoms (the time since the first episode of urticarial wheals), urticaria can be classified as acute (up to 6 weeks) or chronic (over 6 weeks). In acute urticaria second-generation antihistamines are the first choice. For refractory cases, use a combination of H1 and H2 antihistamines(Ranitidine). A short course of an oral corticosteroid (administered daily for 5-7 d, with or without a taper) or a single dose of a long-acting injectable steroid is not usually associated with long-term sequelae and can be helpful when used for an acute episode of urticaria nonresponsive to antihistamines.
Chronic urticaria (presenting with wheals, angioedema, or both) is of two types i.e. Idiopathic and Induced(where the cause is known). Urticaria in children should be treated with modern second generation antihistamines ( Cetirizine, Fexofenadine,Loratadine ) .When the response is not good for over two weeks increase the doses of the second generation antihistamines by two-to-four times .
In the treatment of chronic urticaria two or more antihistamines should never be combined. It is also important to remember that the first generation of antihistamine are not indicated in the treatment of chronic urticaria.
Bilastine is one of the newest drugs in the second generation antihistamines which is being evaluated.
When despite such management the symptoms still persist add montelukast. Further additions like cyclosporine A, omalizumab or other modalities should be considered.