Chronic Urticaria Clinical Practice Guidelines (BAD, 2021)

Guidelines on the management of chronic urticaria were first published in November 2021 by the British Association of Dermatologists (BAD) in the British Journal of Dermatology.^[1] Selected recommendations are outlined below.

All Types of Chronic Urticaria

Consider the use of topical antipruritic agents (eg, menthol-containing emollient) (good practice point [GPP]).

Patients should avoid known triggers or exacerbating factors (eg, drugs) and especially triggers for inducible urticarias (GPP).

In persons with angioedema without weals, discontinue angiotensin-converting enzyme (ACE) inhibitors (strong recommendation).

First-line antihistamines for pediatric chronic urticaria are as follows:

Chlorphenamine (2 mg/5 mL oral solution): 1 mg twice daily (BID) for ages 1 month to 1 year
Cetirizine (5 mg/5 mL oral solution or 10 mg tablets): For ages 1-2 years (unlicensed), the dose is 250 mcg/kg BID (typically up to 2.5 mg BID); for ages 2-5 years, 2.5 mg BID; for ages 6-11 years, 5 mg BID; and for ages 12-17 years, 10 mg daily
Desloratadine (2.5 mg/5 mL oral solution or 5 mg tablets): For ages 1-5 years, 1.25 mg daily; for ages 6-11 years, 2.5 mg daily; and for ages 12-17 years, 5 mg daily
Loratadine (5 mg/5 mL oral solution or 10 mg tablets): For ages 2-11 years and weight <31 kg, 5 mg daily; for ages 6-11 years and weight >31 kg, 10 mg daily; and for ages 12-17 years, 10 mg daily
Fexofenadine (30 mg/120 mg/180 mg tablets): For ages 6-11 years (unlicensed), 30 mg BID; and for ages 12-17 years, 180 mg daily

Chronic Spontaneous Urticaria (CSU)

Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in CSU that appears to be exacerbated by this class of drugs (strong).

If tolerated and not contraindicated, consider switching NSAID therapy to a selective cyclooxygenase-2 (COX-2) inhibitor when a history exists of acute CSU exacerbation following NSAID intake for inflammation (weak). Note that there is a lack of evidence of benefit from switching low-dose aspirin used as an antithrombotic to an alternative antiplatelet agent.

Do not routinely advise dietary exclusion. Investigate appropriately if a detailed history indicates that food plays a role (GPP).

Do not offer routine screening for Helicobacter pylori (strong).

First-line treatment options for CSU

Offer a regular daily licensed dose of a second-generation H₁-antihistamine (strong).

First-generation H₁-antihistamine options in adult CSU are as follows:

Chlorphenamine: 4 mg every 4-6 hours, to a maximum of 24 mg/day (elderly maximum: 12 mg/day)
Cyproheptadine: 4 mg three times daily (TID) (maximum: 32 mg/day)
Promethazine: 10-20 mg BID to TID

Second-generation H₁-antihistamine options in adult CSU are as follows:

Acrivastine: 8 mg three times a day
Cetirizine, loratadine, or mizolastine: 10 mg once daily
Desloratadine or levocetirizine: 5 mg once daily
Fexofenadine: 180 mg once daily

If tolerated and not cautioned or contraindicated, offer updosing of one second-generation H₁-antihistamine (up to 4-fold licensed dose) in symptomatic CSU refractory to the standard licensed dose (strong). After total symptomatic control, try stepwise dose reduction. No evidence exists to guide optimum duration of updosing or speed of dose reduction.

Offer therapeutic progression, using first-line treatment options every 2-4 weeks (every 2 wk in severe refractory disease).

Unless no alternative exists, do not routinely offer first-generation H₁-antihistamines given concerns regarding their central nervous system (CNS) effects (short, long term) (strong). Unless no other option exists, do not offer long-term systemic corticosteroids (strong). Use the lowest effective dose for the shortest possible period.

Do not updose mizolastine, and do not updose first-generation H₁-antihistamines (both strong).

Inducible Urticarias

First-line treatment options for inducible urticarias

Offer a regular daily licensed dose of a second-generation H₁-antihistamine (strong).

If tolerated and not cautioned or contraindicated, offer updosing of one second-generation H₁-antihistamine (up to 4-fold licensed dose) in symptomatic inducible urticaria refractory to the standard licensed dose (strong). After total symptomatic control, try stepwise dose reduction. No evidence exists to guide optimum duration of updosing or speed of dose reduction.

Unless no alternative exists, do not routinely offer first-generation H₁-antihistamines given concerns regarding their CNS effects (short, long term) (strong).

Do not updose mizolastine, and do not updose first-generation H₁-antihistamines (both strong).

For more information, please go to Chronic Urticaria and Urticaria.

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