Treatment of chronic urticaria

Treatment of chronic urticaria

General tips for treatment of chronic urticaria

• Advise your patient to avoid triggering factors if known.
• Educate your patient about avoiding possible physical stimuli (heat- tight clothes- etc) in case of physical urticaria.
• Second generation H1 antihistamines are the first line of treatment in all guidelines.
• Diet modification and avoidance of food additives may be helpful in some cases.
• Vitamin D supplementation 4,000 IU/d for 4–12 weeks might help to decrease the disease activity in some patients.

According to EAACI/GA²LEN/EDF/WAO guidelines:

• If the response is not adequate, increasing the dose of second generation H1 antihistamines up to 4 folds is recommended.
• If no adequate response, Omalizumab should be added to second generation H1 antihistamines.
• If no adequate response and in case of refractory urticaria, Cyclosporine can be added to second generation H1 antihistamines.
• Short term use of steroids may be required.

According to AAAAI guidelines:

• Second line treatment options:
  • Increasing second generation H1 antihistamines.
  • Add another second generation H1 antihistamines.
  • Add H2 antagonist.
  • Add leukotriene receptor antagonists.
  • Add first generation H1 antihistamines at bed time.

• If not adequate:
  • Add Omalizumab or Cyclosporine.

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 Medical treatment options

• Second generation H1 antihistamines
  • Cetirizine: adult dose 10 mg/day.
  • levocetirizine: 5 mg once daily.
  • Loratadine: adult dose 10 mg daily.
  • Desloratadine: adult dose 5 mg daily.
  • Rupatadine: adult dose 10 mg daily.
  • Fexofenadine (adult dose 180 mg/day)

• H2 antihistamines
  • Ranitidine : adult dose 150 mg twice a day.
  • Famotidine: 20 mg twice daily.
  • Cimetidine: 400 mg twice per day.
• Leukotriene receptor antagonists
  • Montelukast: adult dose 10 mg once daily.
  • Zafirlukast: adult dose 20 mg daily.

• First generation H1 antihistamines
  • Doxepin:10-50 mg at night.
  • Chlopheniramine: 4 mg three times per day( up to 12 mg at night).
  • Hydroxyzine: 10-25 mg three times daily( up to 75 mg at night).
  • Diphenhydramine: 10-25 mg at night.

If no adequate response to high doses antihistamines, the following options have to be considered for refractory and severe urticaria.

• Omalizumab (Xolair®)
  • Used combined with second generation H1 antihistamines until the patient shows a complete response to Omalizumab.
  • The dosage is 300 mg every four weeks subcutaneously.
  • If no improvement, the minimum period for using Omalizumab before shifting to another line of treatment is 6 months.
  • If the patient shows complete response to Omalizumab, the interval between doses can be increased by one week each cycle until eight week interval reached and then you can try stoppage of the treatment.
  • If relapse happened, you can retreat the patient using Omalizumab again.
  • For partial responders, you can consider adding low dose cyclosporine.
  • Patients must be prescribed an epinephrine autoinjector because anaphylaxis is reported 
  • It has been used safely in pregnant women and is the treatment of choice for refractory CSU during pregnancy.

• Cyclosporine : 3–4 mg/kg/day.
• Colchicine : 0.6 mg twice daily.
• Sulfasalazine : 500 mg/d and increased by 500 mg each week up to 1 gram twice per day.
• Dapsone (50-150 mg once daily)
  • In cases with neutrophil-rich infiltrate on biopsy.
  • Pretreatment and follow up G6PD, Liver function tests and CBC have to be done.

• Systemic steroids
  • Prednisolone : 0.5 mg/kg/day as rescue treatment over 1–3 days, Prolonged use should be avoided.
• Mycophenolate : 1000-2000 mg twice per day.
• Hydroxychloroquine :  200 mg twice per day.
• Levothyroxine: 50-125 mcg.
• Danazol
  • Danazol should be considered in treatment of severe cholinergic urticaria not responding adequately to antihistamines.
  • Side effects include virilizing effects and hepatotoxicity.
  • Danazol should be avoided during pregnancy.
  • Dose : 200 mg three times daily.

• Methotrexate
  •  5 to 25 mg/week.

Physical treatment options

• Narrowband UVB (NB-UVB) phototherapy.
  • Mainly for highly symptomatic dermographism.

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