Chronic urticaria (CU), a common disease, represents a significant burden for many patients. The current urticaria guideline explains the evidence-based diagnosis and treatment of CU; however, it does not describe everyday practice.

May 2020 witnessed a digital meeting with German urticaria experts, which discussed practical aspects of CU treatment and also formulated supporting aids for everyday clinical treatment. The resulting advice in this manuscriptguided practice questions and also focused on the available literature and experiences of the participants.

Summary and conclusion for clinical practice:

• The diagnosis of CU can be made in a little time utilizing a detailed anamnesis, a physical examination and a basic laboratory chemical diagnosis. 
• For the anamnesis, a short basic form or the more detailed Chronic Urticaria Registry(CURE) patient forms for initial and follow-up presentations are appropriate.
• An extended diagnostic evaluation is only indicated in a few cases and should always be performed in parallel with effective therapy.
• Angioedema is frequently underdiagnosed in patients with chronic spontaneous urticaria (csU), although they can be part of csU independent of the presence of wheals and can harm the quality of life and daily activities.
• Thus, a csU is always treated similarly, independent of the presence of wheals angioedema, or both.
• Second-generation H1-antihistamines are the treatment of choice for csU. Higher doses, nearly four times the standard dose, are usually more effective but are off-label use and may not be tolerated by every patient. In most patients, however, a higher dosage of the standard dose is unproblematic if potential risk factors or comedication are assessed (no signs of cardiotoxicity).
• If no adequate improvement is seen after 2 to 4 weeks with a second-generation H1-antihistamine in the standard dosage or, if necessary, after higher dosages, patients with csU can additionally be administered omalizumab.
• The therapy of chronic inducible urticaria (CIndU) is comparable to the therapy of csU. For patients suffering from both CIndU and csU, omalizumab therapy can be used within the label.
• Omalizumab shows a good safety profile with a low anaphylaxis rate.
• In cases of mild rhinitis, cough or hoarseness, omalizumab can be dispensed without trouble.
• Both inactivated and live vaccines can be dispensed under omalizumab therapy.
• Patients without any medical history of anaphylaxis can inject omalizumab themselves or have a caregiver inject it from the fourth application onwards (except for pregnant women).
• If no therapeutic success is achieved after 6 months of treatment with omalizumab, off-label use with ciclosporin A along with existing therapy with H1-antihistamines is recommended by the guidelines instead.
• At times of acute exacerbations, treatment with medium-dose oral-systemic glucocorticoids can be given for a short period (up to 10 days maximum) to lessen disease duration and activity.
• If clinically essential, using second-generation H1-antihistamines (loratadine, cetirizine) and omalizumab during pregnancy may be considered (off-label).
• Good documentation and education of patients about off-label use are of great importance (the responsibility lies with the treating physician).

This documentation helps to ensure that patients suffering from CU achieve complete freedom of symptoms with the help of optimal therapy.

Source: Bauer A, Dickel H, Jakob T, et al. Expert consensus on practical aspects in the treatment of chronic urticaria. Allergo J Int. 2021;30(2):64-75.