Table of contents
Chronic urticaria
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of chronic urticaria are prepared by our editorial team based on guidelines from the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI/GA²LEN/EDF/EAACI 2022) and the British Association of Dermatologists (BAD 2022).
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Classification and risk stratification
Classification, based on duration: as per APAAACI/EAACI/EDF/GA²LEN 2022 guidelines, classify urticaria as acute (≤ 6 weeks) or chronic (> 6 weeks).
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Classification (based on trigger)
Differential diagnosis
Diagnostic investigations
Clinical assessment: as per APAAACI/EAACI/EDF/GA²LEN 2022 guidelines, use the urticaria activity score 7 and/or angioedema activity score to assess disease activity in patients with chronic spontaneous urticaria.
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Initial evaluation
Provocation tests
Medical management
Goals of treatment: as per APAAACI/EAACI/EDF/GA²LEN 2022 guidelines, target complete symptom control in patients with urticaria, considering as much as possible the safety and the QoL of each individual patient.
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Avoidance of inciting agents
H1RAs
H2RAs
Leukotriene receptor antagonists
Systemic corticosteroids
Omalizumab
Cyclosporin
Epinephrine autoinjectors
Third-line therapy (chronic spontaneous urticaria)
Third-line therapy (chronic inducible urticaria)
Nonpharmacologic interventions
Dietary modifications
As per BAD 2022 guidelines:
Do not advise routine dietary exclusion in patients with chronic spontaneous urticaria. Obtain appropriate evaluation if food appears to play a role, based on a detailed history, in patients with chronic spontaneous urticaria.
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Insufficient evidence regarding dietary supplementation in patients with chronic spontaneous urticaria.
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Emollients
Psychosocial support
Specific circumstances
Pediatric patients: as per APAAACI/EAACI/EDF/GA²LEN 2022 guidelines, consider using the same treatment algorithm with caution (weight-adjusted dosage) in pediatric patients with chronic urticaria.
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Pregnant patients
Patient education
Follow-up and surveillance
Indications for referral: as per BAD 2022 guidelines, refer patients with chronic urticaria to secondary care in the following situations:
diagnostic doubt
urticaria is not adequately controlled by first-line therapy
high levels of inflammatory markers
marked or persistent associated systemic symptoms, or if the patient is systemically unwell
urticaria is having a significant impact on QoL, such as depression, anxiety, marked psychosocial impact, reduced work/school attendance or sleep disturbance
angioedema without weals not controlled by first-line therapy.
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Clinical follow-up