Chronic Urticaria: Following Practice Guidelines

Erin P. Westby, MD; Charles Lynde, MD, FRCPC; Gordon Sussman, MD, FRCPC, FACP, FAAAI


Skin Therapy Letter. 2018;23(3):1-4. 

In This Article


National and international guidelines recommend avoidance of intensive and costly general screening for causes of urticaria, relying largely on history, physical examination, and appropriate follow-up. Recently updated and revised international guidelines suggest a step-wise approach to the management of chronic spontaneous urticaria. These proposed recommendations have yet to be published but represent a framework for further review by respective national and international boards before adoption. In sum, these guidelines suggest that first-line therapy includes second-generation non-impairing, non-sedatingH1-antihistamines. If no response by 2–4 weeks, up-dosing with second-generationH1-antihistamines, up to fourfold increase, has been widely adopted as a safe and efficacious second-line therapy when treatment is inadequate with standard therapeutic dosages. A large body of data has demonstrated that omalizumab, a biologic agent, is safe and effective in the treatment of H1– antihistamine refractory urticaria and should be considered as a third-line agent, with cyclosporin A reserved for fourth-line therapy.