Fast Five Quiz: Chronic Spontaneous Urticaria

William D. James, MD


June 15, 2020

Both the American Academy of Allergy, Asthma, and Immunology (AAAAI) and the European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA2LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO) recommend second-generation antihistamines as the first-line treatment for CSU.

Second-generation antihistamines are low-sedation antihistamines that are effective in decreasing the intensity of hives and pruritus. Although a leukotriene receptor agonist can be given as add-on therapy if needed to help control symptoms, this class of drugs is not an effective monotherapy for CSU.

Long-term treatment with a corticosteroid is generally not recommended for patients with CSU; however, short-course corticosteroid therapy may be indicated for severe autoimmune urticaria that is refractory to high-dose oral antihistamine therapy. Methotrexate may also be beneficial. In the unlikely event that long-term corticosteroid therapy is necessary, patients should be regularly monitored for bone density changes and adverse ocular effects.

First-generation H1 antihistamines are not recommended as first-line treatment for CSU owing to their sedative side effects. However, when indicated, a first-generation antihistamine can be added to existing therapy and given at nighttime to provide relief from pruritus, which is often worse at night. Because first-generation H1 antihistamines are associated with adverse side effects in elderly patients, clinicians should use extreme caution when considering their use in this patient population. Additionally, doxepin should be avoided in patients with glaucoma.

Although low-dose vitamin D3 supplementation is not recommended as a first-line therapy for CSU, studies on high-dose vitamin D3 supplementation (4000 IU/day) showed lower symptom severity scores in a 12-week clinical trial involving 42 patients with chronic urticaria. Therefore, vitamin D3 supplementation may be considered as an add-on therapy.

For additional information, refer to treatment guidelines.

Learn more about the treatment of CSU.


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