Abstract
Urticaria is a common disorder with diverse clinical presentations. Correct recognition of the different clinical patterns promotes more effective treatment. Management involves treatment of any identifiable external causes, including infection, avoidance of drug, food and physical triggers and the appropriate use of pharmacological therapies. These can be divided into first-, second- and third-line approaches. The choice of treatment will be influenced by many factors, including drug licensing, safety, pattern of disease, disease severity, pharmacoeconomic considerations and patient preference. H1 antihistamines are the mainstay of treatment of most patterns of urticaria and are effective in the majority of patients with mast cell-mediated disease. Second-generation antihistamines have a better therapeutic index and improved pharmacodynamic properties compared with older ‘classic’ antihistamines and should be prescribed preferentially for chronic urticaria. Patients who are unresponsive to H1 antihistamines at full dose may require short-term treatment with oral corticosteroids but their long-term use for urticaria should be avoided whenever possible on account of the risk of serious adverse effects. Antileukotrienes and alternative second-line agents, prescribed off licence, can be helpful for patients who respond poorly to antihistamines when taken in conjunction but a better evidence base is needed to guide prescribing. Third-line immunosuppressive therapies can be considered for debilitating urticaria, especially for patients with corticosteroid-dependent chronic disease, and may have some potential to modify the natural course of the illness. Possible new therapeutic approaches on the horizon include new H1 antihistamines, H4 receptor antagonists, a histidine decarboxylase inhibitor under development and biological agents that target histamine-releasing autoantibody production and function.