Urticaria and Angioedema

"6 Therapy of Urticaria (p. 129-130)

Bettina Wedi

Core Messages

The different urticaria subtypes are common skin diseases persisting often for › years with multifactorial triggering factors and greatly reduced quality of life as well as occupational disability. Therapy can be problematic and is not standardised. Regarding the long duration › of this annoying skin disease, every attempt should be made to identify and avoid speci? c or unspeci? c triggering factors. The treatment goal is to maximise the quality of life, to maintain vigilance and ability to work or to attend school and to minimise drug-related side effects.

Besides antihistamines and the eradication or avoidance of identi? ed triggering › factors, many drugs, most of which are not licensed for urticaria, are administered. The highest grade of recommendation (GoR) according to the criteria of › evidence-based medicine can only be given for second-generation H1 antihistamines. They should be administered in an adequate dose, up to fourfold the normal dose while considering potential side effects. The data on treatment alternatives are totally insuf? cient. Good evidence exists in › severely affected patients for cyclosporin A. Subgroups might bene? t from addition of leukotrienes antagonists. Chloroquine and dapsone may be worthy of further investigation within randomised controlled trials.

The risk–bene? t pro? le of each alternative (off-label use) to second-generation › H1 antihistamines should be carefully considered before treatment. This applies especially to immunosuppressive agents. The clinical pictures of urticaria are of heterogeneous aetiology and therefore subclassi? ed into distinct groups, which can coexist: spontaneous urticaria, physical urticaria and special types. To optimise urticaria treatment, the ? rst strategy should be to correctly classify the respective urticaria subtype. The treatment goal is to maximise the quality of life and ability to work or to attend school and to minimise drug-related side effects.

This is of particular importance regarding the long year duration of many urticaria subtypes. Relevant outcomes of treatment trials include pruritus, weal size, number and frequency, loss of awakening, overall physician and patient assessment and permanent remission of disease. This chapter is based on the results of two recent publications evaluating randomised controlled trials (RCTs) of urticaria therapy (until October 2004) according to the criteria of evidence-based medicine [1, 2 ].

Details of the individual studies, inclusion and exclusion criteria as well as the cited literature are available in the publications [1, 2 ], if not otherwise cited. Additionally, this review includes at least the RCTs published until December 2006 [3–7 ] and also interesting treatment approaches. In the text, the respective GoR according to the criteria of evidence-based medicine of the Scottish Intercollegiate Guidelines Network (SIGN; www.sign.ac.uk, GoR A to D, whereas A represents best evidence) is given in parentheses. Table 6.1 summarises the recommended therapeutic approaches."