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Chronic urticaria

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).


1.Classification and risk stratification

Classification, based on duration: classify urticaria as acute (≤ 6 weeks) or chronic (> 6 weeks).
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  • Classification (based on trigger)

  • Differential diagnosis

2.Diagnostic investigations

Clinical assessment: 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

3.Medical management

Goals of treatment: 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)

4.Nonpharmacologic interventions

Dietary modifications
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.
Insufficient evidence regarding dietary supplementation in patients with chronic spontaneous urticaria.

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  • Emollients

  • Psychosocial support

5.Specific circumstances

Pediatric patients: consider using the same treatment algorithm with caution (weight-adjusted dosage) in pediatric patients with chronic urticaria.

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  • Pregnant patients

6.Patient education

Patient education: provide patients with educational material or a patient information leaflet on urticaria and angioedema.

7.Follow-up and surveillance

Indications for referral: 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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  • Serial clinical assessment