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Abstract
Chronic spontaneous urticaria (CSU) is characterized by the recurrence of itchy wheals for at least 6 weeks, affects up to 1% of the general population and may severely impair quality of life. H1-antihistamines are the cornerstones of treatment, but in about 10% of cases they fail to control the disease even at higher than licensed doses. In these patients, short courses of oral steroids may induce a remission in about 50% of cases. Omalizumab, a monoclonal anti-IgE, is effective in antihistamine-unresponsive patients although optimal treatment duration needs to be defined. Immunosuppressive treatment with cyclosporine is also effective in the majority of antihistamine-resistant chronic spontaneous urticaria (CSU) patients, but its use is limited by potential side effects. In refractory patients, other approaches include intravenous immunoglobulin, rituximab, dapsone and anticoagulants. The present review looks with particular interest at the prevalence of treatment failures with the main third-level treatments (corticosteroids, omalizumab and cyclosporine) and discusses them in light of the possible different pathogenic mechanisms underlying chronic spontaneous urticaria.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Chronic spontaneous urticaria is a frequent disorder that may heavily worsen the quality of life.
Chronic spontaneous urticaria may be severe and unresponsive to H1-antihistamine treatment.
In severely affected patients, several drugs have been used but only systemic steroids, cyclosporine and omalizumab are presently recommended by the guidelines.
Systemic steroids are extremely effective but cannot be used in the long term due to side effects.
Cyclosporine is effective and can be used for long-term treatments, but is associated with some side effects and many pharmacological interactions.
Omalizumab is effective and well tolerated but quite expensive.
Some patients fail to respond to one or more of these three drugs.
A better knowledge of the pathogenic mechanisms underlying the disease will lead to understand better the reasons for these failures and to a more patient-tailored therapy.