British Association of Dermatologists guidelines for the management of people with chronic urticaria

Urticaria is common, affecting one in five people during their lifetime. It consists of itchy, raised lumps, called weals or hives. Individual weals last for a few hours and resolve, leaving no trace. However, more profound, longer‐lasting, sometimes tender swellings affecting the eyelids, lips or mouth (angio‐oedema) may also occur. Urticaria is considered ‘acute’ if it persists for less than six weeks and ‘chronic’ if it lasts longer. Chronic urticaria can occur spontaneously (chronic spontaneous urticaria). Alternatively, it can be induced by various triggers (chronic inducible urticaria), such as friction (dermographism), pressure (delayed‐pressure urticaria), sweating (cholinergic urticaria), cold (cold urticaria), sun (solar urticaria) or water (aquagenic urticaria). This guideline explains the management of the different types of chronic urticaria. The aim is disease control because there is no cure yet. Therefore, no, or very few, investigations are needed, as usually no cause is found. It is essential to avoid factors that may make urticaria worse, including some drugs. For example, a menthol‐containing cream may help with the itching. Treatment starts with a low-sedating antihistamine for all types of chronic urticaria, increased, if needed and safe, above licensed dose. Sedating antihistamines are best avoided. For chronic spontaneous urticaria, montelukast can be added. Sometimes, steroid tablets (prednisolone) are given for a few days to calm a bad flare, but not for long‐term use. For severe chronic spontaneous urticaria, omalizumab injections are usually considered next. Ciclosporin tablets are the alternative. Finally, other treatment options are listed. For severe chronic inducible urticaria, omalizumab is given in countries where it has been approved. Self-injectable adrenaline is provided if there are episodes of collapse. The following treatment depends on chronic inducible urticaria, e.g. phototherapy can be considered for dermographism or ciclosporin for cold urticaria. The guideline explains therapy in pregnancy, breastfeeding patients, and children. There are research recommendations and information on exciting new treatments in development.