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Chronic Spontaneous Urticaria

  • Patients with chronic spontaneous urticaria are often frustrated and anxious
  • Although no external cause is identified in most patients, numerous factors can aggravate the condition.
  • Understanding these triggers and learning to avoid those that are relevant to the individual patient are critical components of successful management. Education should begin as soon as the diagnosis is made.
  • H1 antihistamines are recommended as initial therapy for all patients with chronic spontaneous Urticaria.
  • Less-sedating, second-generation agents (eg, cetirizine, levocetirizine, fexofenadine, loratadine, desloratadine)are more recommended over older first-generation agents (eg, hydroxyzine, diphenhydramine, chlorpheniramine, or mizolastine)

Treatment Response

  • Around 50% of the patients may not achieve complete control of symptoms using standard doses of second-generation H1 antihistamines alone.
  • a stepwise approach to increasing therapy is appropriate for this patient group(Non Responders).
  • As we increase doses or as different agents are introduced, it is important to discontinue any that have not been beneficial, so that medications do not accumulate


One or more of the following interventions are recommended for those who have persistent symptoms:

  1. Increasing the dose of the second-generation H1 antihistamine to up to four times the standard dose (after which, international guidelines suggest adding omalizumab)
  2. Adding a different second-generation antihistamine
  3. Adding an H2 antagonist
  4. Adding a leukotriene-receptor antagonist
  5. Adding a first-generation H1 antihistamine at bedtime