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International guidelines for the treatment of chronic spontaneous urticaria support the updosing of second-generation antihistamines to four times of the approved dose when adequate symptom control cannot be achieved with the standard dosage. However, this recommendation is primarily based on expert opinions, and there is a lack of large, well-designed, double-blind clinical trials. Most the existing trials provide insufficient data, and due to the heterogeneity of the conducted trials on antihistamine effects (definition of control, design, quality, lack of an active comparator, no placebo arm, small sample size, outcomes) and their short duration, comparative analysis is challenging. However, it can be concluded that the use of modern second-generation antihistamines is both effective and safe based on the available data and our own long-term experiences in the specialized outpatient clinic of a university dermatology department, even though increased dosages (up to fourfold as per the current international guidelines) may be necessary for symptom control. Another therapeutic option for refractory symptoms in chronic spontaneous urticaria is subcutaneous administration of omalizumab at a dosage of 300 mg at 4‑week intervals as a very safe and effective treatment., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Urticaria is a very common skin disease which was already described in the ancient world. Questions still remain about its pathogenesis and management remain open. Compared to other common skin diseases, the published evidence is rather low. The clinical symptoms with pruritic transient wheals and/or angioedema are caused by mediators (particularly histamine) released by activated mast cells and basophils. The mechanism of target cell activation has not been clarified in detail for most urticaria subtypes. Different urticaria subtypes should be distinguished. Spontaneous forms are more common than inducible forms. Chronic urticaria and urticaria in certain age groups (children, pregnancy) can be difficult to manage. Therefore, international consensus resulting in the regular update of urticaria guidelines can be very helpful. Currently, these updated guidelines include a three-step treatment algorithm for chronic spontaneous urticaria. Only the first step of this algorithm, second generation H1-antihistamine in standard dose, utilized approved drugs. However after omalizumab was established as a third line choice in the guideline algorithm, it has approved in many countries for chronic spontaneous urticaria without response to H1-antihistamines. The exact mechanism of action of omalizumab in urticaria has not been fully elucidated. Unrevealing this mechanism might result in a deeper understanding of urticaria pathogenesis and the development of further therapeutic strategies., (© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd.)

According to the guidelines the treatment goal for all types of urticaria is to achieve complete symptom relief. Therefore the available literature for urticaria treatment was reviewed regarding this aim and treatment failure, respectively. Systematic studies are not available. Standard doses of H1-antihistamines are the only approved therapy. Review of the limited data where statements are made about complete alleviation of symptoms shows that standard doses of H1-antihistamines rarely achieve this. Even when the dosage is increased up to four-fold, the failure rate is high. Additional therapy with montelukast, dapsone, and cyclosporine A also often fails to produce complete control. For severe chronic spontaneous urticaria, controlled studies using omalizumab have shown low failure rates over long time periods. It has not been investigated whether up-dosing or reduced injection intervals could further improve this rate. Taken together, the small amount of available data on complete symptom relief in urticaria treatment is astonishing. Moreover, the studies can not be compared due to different inclusion criteria (severity of urticaria, allowed basic treatment) and evaluated parameters. Further controlled studies are vitally needed to achieve the goal of complete symptom relief in urticaria.

There are specific diagnostic recommendations for approaching chronic spontaneous urticaria, physical urticaria and special forms of urticaria. They include the detection of subclinical viral and bacterial infections, particularly with Helicobacter pylori. Frequently an autoimmune urticaria is diagnosed by using the autologous serum test. Less specific findings, such as leukocytosis and elevated CRP can sometimes be helpful in suggesting subclinical infections as the cause of acute urticaria; usually no further procedures are recommended. However, in cases with a long history of intermittent attacks, particularly with severe and generalized symptoms, it is recommended to look for IgE-mediated reactions (e.g. alpha-Gal, Omega-5-Gliadin). In our hands at the Department of Dermatology and Allergy at the Hannover Medical School a standardized set of diagnostic procedures was successfully established, and is now individually completed with selected single allergens and allergen components.

A 27-year-old woman presented with severe pruritus for a few weeks and diffuse urticarial erythema with pinhead-sized papules over the entire body. The skin lesions occurred directly after a stay in her secondary residence in London. The medical history, clinical picture and histological feature of an arthropod reaction in the skin biopsy, coupled with patient offering a bed bug specimen as evidence, secured the diagnosis of a cimicosis.

Urticaria represents a common skin reaction pattern that can be induced by different factors. Triggering by infections has been discussed for many years but the exact role and mechanism of mast cell activation by infectious processes is unclear. In acute spontaneous urticaria, there is no doubt about a causal relationship to infections and all chronic urticaria must start as acute. Remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Summarizing available studies evaluating the course after proven Helicobacter eradication demonstrates a statistically significant benefit compared to not-eradicated or Helicobacter-negative patients. The licensed treatment with a standard dose of H1-antihistamines is not effective in a significant number of patients and infections can be easily treated. Therefore, appropriate diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori.

The different urticaria subtypes represent a common diagnostic and treatment challenge for the dermatologist. Usually, acute urticaria is treated symptomatically with modern H1 antihistamines and, if needed, short courses of glucocorticosteroids. In acute urticaria which is often induced by an acute infection no further diagnostic procedures are recommended. In contrast, a targeted work-up followed by specific therapy is required for chronic urticaria, physical urticaria and special urticaria types, because many of these subtypes are characterized by their persistence for several years and have a profound impact on the quality of life. This article elucidates the management of urticaria by presenting five characteristic case reports of patients managed in a special urticaria consulting hour.

Urticaria is one of the most common skin diseases. It is divided into several categories including acute and chronic urticaria as well as physical urticaria and special subtypes such as cholinergic and autoimmune urticaria. The causes of urticaria are multiple. In more than 80%, urticaria is triggered by an inflammatory focus, a subclinical infection or autoimmune actions. In addition, non-specific pharmacological or toxin-mediated release of inflammatory mediators from basophils or mast cells can also trigger urticaria. These new aspects in the pathophysiology of urticaria suggest new and promising therapeutic strategies. The first line treatment of urticaria still consists of non-sedating H1-antihistamines. Since urticaria has a profound impact on quality of life, effective treatment is very important. We consider new therapeutic options based on our long-term experience in treating patients with urticaria.

Chronic urticaria in children occurs more often than it might be supposed, but its management is not part of the usual daily routine. While acute urticaria in children can be treated symptomatically without further investigations, chronic urticaria requires a search for trigger factors. Autoimmune urticaria can occasionally be documented in children. The treatment of chronic urticaria depends on the suspected trigger, always keeping in mind that medications may need to be adjusted to meet pediatric requirements.

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Copyright of Der Hautarzt is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Hautarzt is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)