Treatment

The goal of treatment is treating as efficiently and safely as possible reaching a continuous symptom-free state and a normalisation of quality of life. Any treatment should follow the principle of treating as much as necessary and as little as possible.

Frequently, urticaria will resolve on its own without the need for any treatment.

Treatment of urticaria involves identifying and eliminating underlying causes, and avoiding the triggering factorss and symptomatic pharmacological treatmentusing some medications. Consequently, patient education and understanding of the natural history of the disease are important in the management of urticaria.

To ensure optimal treatment for chronic urticaria patients, continuous monitoring and documentation of disease activity is essential. The urticaria app CRUSE® (Chronic Urticaria Self Evaluation) app is developed by renowned dermatologists and allergologists of the UCARE-Team to help chronic urticaria patients to manage their condition.

CRUSE® helps you and your doctor to track disease activity, how you are responding to treatment and how it can be improved. CRUSE® can do all this and much more. The basis for this are the daily questions based on the so-called PROMs. CRUSE® makes it easy to answer the daily questions allowing you to do this on your mobile device instead of paper. Importantly, CRUSE® can help to drive urticaria research and enable the development of novel innovative therapeutic approaches with your help by completing the daily questions on CRUSE® as accurately as possible. Your documentation makes a massive impact .

See the “Triggers and Types” section.

The therapeutic approach includes:

A. Identifying and, if possible, eliminating the underlying causes (e.g. treating infections or inflammatory processes; reducing functional autoantibodies in severe therapy-resistent CSU cases).

B. If known and as far as possible, avoidance of triggering factors (i.e. specific and definite triggers in case of CIndU; non-specific triggers in case of CSU e.g. use of certain medications that are non-steroidal anti-inflammatory drugs or stress) to reduce disease activity.

C. Induction of tolerance in specific cases of CIndU to reduce disease activity.

D. The use of pharmacological treatment to prevent the release of mast cell mediators and/or the effects of mast cell mediators, thereby reducing disease activity.

If urticaria can be tolerated without medical treatment, a few helpful points should be considered by the patient:

A. A. Do not scratch the itchy urticarial lesions and keep as cool as possible by applying cold water (not iced), lotion, and wearing loose-fitting clothing.

B. Try to keep “stress” under control with remediation, relaxation exercises, and Yoga.

BC. Avoid wine and alcoholic drinks and tobacco, which non-specifically can trigger urticaria.

CD. In case of IgE-mediated food allergy, Aavoid the specific food allergens as far as possible.

E. Avoid perfumed emollients, antihistamine creams, and Llanolin (to avoid contact allergy).

DF. Avoid physical triggers if known as far as possible.

E. Try to keep “stress” under control with remediation, relaxation exercises, and Yoga.

F. Avoid foods and some medications with pseudoallergenic agents such as preservatives (e.g. sodiummetabisulfite/E223, sodium benzoate/E211, sorbic acid, butylhydroxyanisol/E320, butylhydroxytoluol/E321, propylgallate/E310), and food dyescolorings (e.g. Ttartrazine), artificial additives (sodium nitrate, sodium glutamateSodium Benzoate, and Sulfites,), and naturally occuring pseudoallergens as Salicylate salicylates (e.g. contained in several types of fruits, vegetables and Berry fruit, Sspices, and strong Tea). Trying a pseudoallergen-free diet for at least three weeks may reduce your symptoms and the burden of pharmacological medication use in 1/3 of patients. The basis of pseudoallergen-free diet is contains more fresh industrially unprocessed food. and eliminates processed foods, additives, dyes, preservatives, phenols, and certain aromatic compounds.

G. Avoid aspirin-containing medication, and flu-remedies and other anti-inflammatory medication (NSAIDs) such as Ibuprofenibuprofen, diclofenac, Mefenamic mefenamic acid and diclofenac, and Codeine codeine (opioideate analgesics), which may also act as urticaria triggers.have the potential to cause flare-ups or to worsen urticaria.

Antihistamines

Antihistamines are long-known effective and safe medications for symptom relief. There are several medications in this group of drugs with similar effects. Antihistamines are drugs from a group of substances that inhibit the effect of histamine. H1-Antihistamines, which block the effect of histamine via the so-called H1 receptor, are successfully used in the treatment of urticaria. In this way, they effectively prevent the development of typical urticaria symptoms, wheals and angioedema. Second generation non-sedating H1-antihistamines ( H1-AH-2G) are the most commonly prescribed medication for urticaria. They can be safely updosed up to fourfold the manufacturer’s recommended standard dose as long-term medication for those patients with chronic urticaria that do not respond well to the standard dosing. Their active ingredients include cetirizine, levocetirizine, loratadine, desloratadine, fexofenadine, ebastine and bilastine. These medications are usually given orally and do not induce sleepiness in most patients. Disease control of urticaria is best achieved by antihistamines when taken regularly. Learn more about antihistamines by listening to episode 77 of “All things Urticaria” podcast via Spotify or via Apple Podcast.

Omalizumab

Omalizumab is an antibody drug that binds and inactivates free IgE autoantibodies and thereby counteracts the activation of mast cells, the key drivers in the development of typical urticaria symptoms, wheals and angioedema. Omalizumab has been shown to be very effective and safe in the treatment of chronic urticaria and is suitable for long-term treatment. Omalizumab is currently approved for the treatment of urticaria patients who do not show sufficient benefit from treatment with an H1-AH-2G . Omalizumab in combination with H1-AH-2G is therefore the next step in the treatment algorithm according to the current S3 guideline for the treatment of urticaria1.

Cyclosporin

Cyclosporin (CSA) is a long-known drug that suppresses unwanted immune responses. CSA counteracts the release of histamine from mast cells, which is a key event in the development of typical urticaria symptoms, wheals and angioedema. According to the current S3 guideline for the treatment of urticaria1, patients with with severe disease, who do not show sufficient benefit from treatment with any dose of anti-histamines in combination with omalizumab, are recommended to be treated with CSA in combination with a modified 2nd generation H1 antihistamine.

According to the current S3 guideline for the treatment of urticaria, it is recommended to do drug therapy in 3 stages. The mechanism of action of this therapy is based on blocking the action of mast cells that play a key role in disease development. Basically, it prevents the release of messenger substances formed by mast cells and its negative effects, which in turn reduces disease activity.

Stage 1 – The first-line treatment is to administer 2nd generation non-sedating H1 antihistamines at single to fourfold (if the standard dose is insufficiently effective) the manufacturer’s recommended standard dose.

Stage 2 – For patients who do not respond to this treatment, the second stage of treatment in addition to antihistamines, according to the treatment algorithm, is omalizumab (second-line treatment) at a single (standard dose) or increased (if standard dose is not sufficiently effective) the manufacturer’s recommended standard dose and/or shortened dosing intervals.

Stage 3 – If stage 2 therapy fails, according to the treatment algorithm, the third stage of treatment is ciclosporin (a drug that suppresses unwanted immune responses) in addition to antihistamines (third-line therapy).

1 (Source: Zuberbier T et al, S3 Guideline Urticaria. Part 2: Treatment of urticaria – German adaptation of the international S3 guideline. J Dtsch Dermatol Ges. 2023)

While most cases of acute urticaria resolve within 1 week, even without treatment. less than 40% of cases become chronic. However, almost 50% of affected people are symptom-free within 1 year.Dependet on the type of chronic urticaria (CU), the time to resolve may strongly vary. In some cases, CU may last for several years before spontaneous remission with the possibility of waxing and waning of symptoms from time to time.

The good news is that urticaria is a benign condition as it is not life-threatening, not contagious, and is easily treatable in most patients. In general, many patients with chronic urticaria respond well to antihistamines alone and have a favorable prognosis and outcome. Importantly, disease control of CU is best achieved by antihistamines when taken regularly and discontinuation for a treatment on demand may be one reason for common treatment failure.

However, urticaria may severely impact the patient’s quality of life as it is disfiguring, unpredictable and intensely itchy, which can interfere with sleep and activity. Urticaria can become unbearable, causing emotional distress, and possibly leading to depression. Learn more about which other diseases circle around urticaria by listening to episode 21 of “All things Urticaria” podcast via Spotify or via Apple Podcast.

Current treatment of urticaria aims to reduce symptoms. To date no causal therapy (eliminating the cause of the disease) for the treatment of urticaria is available. However, efforts of the scientific community continuously increase our knowledge about the pathogenesis of urticaria, paving the way for the development of novel individualized treatment options.

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