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Figure 3. Step-care Approach to the Treatment for CU
STEP 1
• Monotherapy with 2
nd
generation antihistamine
• Avoidance of triggers (e.g., NSAIDs) and relevant physical factors if physical
urtcaria/angioedema syndrome is present
STEP 2
One or more of the following :
• Dose advancement of 2
nd
generation antihistamine used in Step 1
• Add another second generation antihistamine
• Add H
2
-antagonist
• Add leukotriene receptor antagonist
• Add 1st generation antihistamine to be taken at bedtime
STEP 3
Dose advancement of potent antihistamine
(e.g., hydroxyzine or doxepin) as tolerated
STEP 4
Add an alternative agent
• Omalizumab or cyclosporine
• Other anti-inflammatory agents, immunosuppressants, or biologics
• Begin treatment at step appropriate for patient's level of severity and previous
treatment history
• At each level of the step-approach, medication(s) should be assessed for patient
tolerance and efficacy
• "Step-down" in treatment is appropriate at any step once consistent control of
urticaria/angioedema is achieved
Nonpharmacologic Therapies
Î NSAIDs, heat, and tight clothing can exacerbate CU in some patients,
and avoidance of these factors might be beneficial. (C)
Î Avoidance of pseudoallergens in the diet is NOT recommended. (C)
Topical Therapies
ÎPotent topical corticosteroids can improve symptoms from delayed pressure
urticaria but have limited utility in the treatment of diffuse CU. (C)
H
1
–Antihistamines
Î H
1
-antagonists are effective in the majority of patients with CU but
might not achieve complete control in all patients. (C)
Î There are no definitive studies that demonstrate that patients with
refractory CU and a positive ASST result respond differently to certain
medication regimens compared with those patients with CU with a
negative ASST result. (C)
Treatment
